A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?

Urinary frequency for several days

Blood-tinged urine

Highly concentrated urine

Temporary urinary retention

Answer and Explanation

The Correct Answer is D

A.   After removal of an indwelling urinary catheter, it is common for a client to experience urinary frequency for a few days. This is due to the bladder readjusting to its normal function.
B.   Blood-tinged urine may occur after catheter removal, but it is not an expected outcome. It should be assessed and reported if it occurs.
C.   Highly concentrated urine is not typically an expected outcome after catheter removal.
It may indicate dehydration or another issue that should be addressed.
D.   Temporary urinary retention can occur after catheter removal, especially in older adults. This is why it's important to monitor the client for signs of retention, such as discomfort, restlessness, or a palpable bladder.

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Correct Answer is ["A","D","E"]

Explanation

A. Keeping the client's bed in the lowest position helps minimize the potential fall distance if the client attempts to get out of bed.
B. Assessing the client every 4 hours is a good practice for general monitoring but may not be specific to fall prevention. More frequent assessments may be necessary for a client at high risk for falls.
C. Keeping the client's room dark at night can actually increase the risk of falls. It's important to ensure there is adequate lighting to help the client navigate safely.
D. Teaching the client to use the call light allows them to request assistance when needed, reducing the likelihood of attempting to move or get out of bed independently.
E. Placing a fall-risk identification band on the client's wrist helps alert all healthcare providers that the client is at risk for falls. This information is crucial for ensuring appropriate precautions are taken.

A. Elevate the head of the bed no more than 45°. B. Use a transfer device to lift the client up in bed. C. Massage the skin over the client's bony prominences. D. Apply cornstarch to keep sensitive skin areas dry.

Correct Answer is A

Explanation

A. Elevating the head of the bed helps to reduce pressure on bony prominences, especially the sacral area, and can help prevent pressure ulcers. However, the head of the bed should not be elevated more than 30 degrees to 45 degrees to maintain skin integrity.
B. Using a transfer device is important for moving the client safely, but it is not specifically related to maintaining skin integrity.
C. Massaging the skin over bony prominences is not recommended as it can increase friction and shear, which can contribute to pressure ulcer development.
D. Applying cornstarch is not typically recommended for pressure ulcer prevention. It can create a moist environment that may contribute to skin breakdown, especially in areas where moisture can become trapped.

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A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Correct Answer is A

Explanation

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