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 D

Explanation

A. Independently disposing of the remaining medication may not be in compliance with facility policies and could potentially interfere with an investigation into how the medication was left unattended.

B. Returning the medication to the unit's stock for future use is not appropriate, as the vial is already open and its integrity may be compromised.

C. Administering the medication to other clients is absolutely not an option. This could lead to serious harm or even fatal consequences for the other clients involved.

D. When a nurse discovers an open vial of medication left unattended, it is a serious safety concern. The nurse should report the discrepancy immediately to the appropriate personnel or supervisor. This ensures that the situation is addressed promptly and that necessary actions are taken to prevent potential harm to clients.

A. Irrigate the wound with an antiseptic prior to obtaining the specimen. B. Include intact skin at the wound edges in the culture. C. Swab an area of skin away from the wound to identify the usual flora. D. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen.

Correct Answer is D

Explanation

A. Irrigating the wound with an antiseptic prior to obtaining the specimen can introduce substances that may interfere with the accuracy of the culture results. Sterile saline is the preferred solution for wound irrigation.
B. Intact skin at the wound edges should not be included in the culture. The specimen should be obtained directly from the wound bed or drainage.
C. Swabbing an area of skin away from the wound to identify the usual flora is not appropriate for obtaining a wound drainage specimen. The culture should be taken directly from the wound site.
D. Before obtaining a wound-drainage specimen for culture, it is important to cleanse the wound with a sterile solution, such as 0.9% sodium chloride saline irrigation. This helps remove debris and contaminants from the wound site, providing a more accurate specimen for culture.

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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

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