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 C

Explanation

A. Washing the tablet off with alcohol and placing it in a clean medication may not effectively remove all potential contaminants and could alter the medication. It's safer to discard it.
B. Using the tablet's packaging to pick it up may not guarantee that the tablet is still clean or free from contamination.
C. Discarding the tablet and obtaining another dose of medication is the safest and most appropriate action. This ensures that the client receives a clean and uncontaminated dose of medication.
D. Placing the tablet directly into a medication cup without any further cleaning is not recommended, as it could introduce potential contaminants into the client's medication.

A. Checking the pupillary response to light B. Eliciting the gag reflex C. Testing visual acuity D. Observing for facial symmetry

Correct Answer is A

Explanation

A. Cranial nerve III, also known as the oculomotor nerve, controls the muscles that move the eye and regulates the size of the pupil. Assessing the pupillary response to light helps evaluate the function of this nerve.
B. Eliciting the gag reflex is associated with cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve III.
C. Testing visual acuity is primarily associated with cranial nerve II (optic nerve), not cranial nerve III.
D. Observing facial symmetry is important for assessing cranial nerve VII (facial nerve), not cranial nerve III.

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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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