A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following information should the nurse include in the teaching?
"You will have a leg bag to collect the urine."
"You will feel pressure when I inflate the catheter balloon."
"You cannot drink fluids for 4 hours after the procedure."
"You will need to urinate before the procedure."
The Correct Answer is D
Choice A Reason:
Choice B Reason:
Inflating a catheter balloon is typically not part of intermittent catheterization, as it is more commonly associated with indwelling catheters.
Choice C Reason:
There is no need for the client to restrict fluid intake before or after intermittent catheterization. In fact, adequate hydration is generally encouraged.
Choice D Reason:
Intermittent catheterization involves inserting a catheter into the bladder to empty it completely, typically to measure residual urine. Before performing intermittent catheterization, it's essential for the client to try to urinate naturally to ensure that the bladder is as empty as possible. This step helps to provide accurate measurements of residual urine and reduces the risk of complications. Therefore, the nurse should include this information in the teaching to ensure the client understands the procedure's proper preparation. While the use of a leg bag to collect urine may be part of the overall management plan, it is not specific to the teaching about preparing for intermittent catheterization.Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
The correct answers are b, c, and d.
a. It is not appropriate for the nurse to threaten the client's child with reporting for maltreatment without
further assessment and evidence.
b. Asking the client's child to provide details regarding the client's fractured arm will provide additional information about the client's injury and help the nurse assess the potential for abuse or neglect.
c. Discussing respite care options with the client's child may help alleviate any caregiver stress or burden, and ensure the client's continued care and safety.
d. Speaking to the client privately will help establish trust and rapport, and allow the client to disclose any concerns or issues that they may not feel comfortable sharing in front of their child.
e. Providing legal advice regarding power of atorney is not within the scope of nursing practice and should be referred to a legal professional. Additionally, the client's capacity to make decisions and appoint a power of atorney should be assessed before providing such advice.
Correct Answer is B
Explanation
Choice A Reason:
Wiping from the outer to the inner canthus is not necessary and may cause contamination.
Choice B Reason:
Apply pressure to the lacrimal punctum after administering the drops. After administering eye drops to a child, it is important to gently apply pressure to the lacrimal punctum (located in the inner corner of the eye) for about 1-2 minutes. This helps prevent systemic absorption of the medication and reduces the risk of it going into the nasopharynx and digestive system. The other options are not recommended:
Choice C Reason:
Positioning the child side-lying is not typically required for administering eye drops.
Choice D Reason:
Rinsing the eye with normal saline before administering the drops is not a standard practice and is not recommended unless there is a specific reason to do so, such as eye irritation or foreign body removal.
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