In assessing a client with an indwelling urinary catheter following the provision of care by an unlicensed assistive personnel (UAP), the practical nurse (PN) observes that the catheter drainage bag, which is half- full, is attached to the side rail and the tubing is looped on the bed.
Which action should the PN implement?
Apply gloves and empty the drainage bag
Remove the looped tubing from the bed
Measure the urinary output in the bag
Attach the drainage bag to the bed frame
The Correct Answer is D
The correct answer is choice d. Attach the drainage bag to the bed frame.
Choice A rationale:
Applying gloves and emptying the drainage bag is not the immediate priority. The drainage bag should not be allowed to overfill, but in this scenario, it is only half-full.
Choice B rationale:
Removing the looped tubing from the bed is important to ensure proper drainage and prevent backflow, but it does not address the incorrect placement of the drainage bag.
Choice C rationale:
Measuring the urinary output in the bag is a routine task but does not correct the improper placement of the drainage bag.
Choice D rationale:
Attaching the drainage bag to the bed frame is the correct action. The drainage bag should be kept below the level of the bladder and attached to a non-movable part of the bed to prevent backflow and reduce the risk of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
This statement is incorrect. Major Depressive Disorder (MDD) is typically more severe than dysthymia and is characterized by recurrent episodes of severe depression lasting at least two weeks.
Choice B rationale:
This statement is incorrect. Dysthymia is not characterized by alternating episodes of mania and depression. It is a chronic, low-grade depressive disorder.
Choice C rationale:
This statement is incorrect. Dysthymia can impair social and occupational functioning, similar to MDD. Both conditions can have a significant impact on a person's daily life.
Choice D rationale:
This statement is accurate. Dysthymia is a chronic depressive disorder that lasts for at least two years but is generally less severe than MDD. It is characterized by persistent, milder symptoms of depression.
Correct Answer is A
Explanation
This is the correct answer because it is the most relevant and respectful question to ask the client next. Asking about the onset of the voices can help the practical nurse (PN) determine the possible causes and triggers of the client's hallucinations, which are sensory perceptions that occur without external stimuli. Hallucinations can be caused by various factors, such as mental disorders, substance abuse, medication side effects, physical illnesses, sleep deprivation, or stress. The PN should ask about the frequency, duration, and content of the voices, as well as the client's response to them. The PN should also assess the client's mood, behavior, cognition, and insight. The PN should use a calm, supportive, and nonjudgmental approach when communicating with the client who is experiencing hallucinations.
a) "Are you planning to obey the voices?"
This is not the correct answer because it is not a priority question to ask the client next. Asking about the client's intention to obey the voices can help the PN assess the risk of harm to self or others, which is an important aspect of safety. However, this question may also imply that the PN believes or validates the voices, which may reinforce the client's delusions or false beliefs. The PN should ask about the client's plan to obey the voices only after establishing rapport and trust with the client, and after assessing the nature and content of the voices.
b) "Have you taken any hallucinogens?"
This is not the correct answer because it is not a respectful question to ask the client next. Asking about the client's substance use can help the PN identify the possible causes of hallucinations, as some drugs such as LSD, psilocybin, or ketamine can induce hallucinogenic effects. However, this question may also sound accusatory or confrontational, which may offend or alienate the client. The PN should ask about the client's substance use in a sensitive and nonthreatening manner, and after obtaining informed consent and ensuring confidentiality.
d) "Do you believe the voices are real?"
This is not the correct answer because it is not a helpful question to ask the client next. Asking about the client's belief in the reality of the voices can help the PN assess the level of insight or awareness that the client has about their condition. However, this question may also challenge or invalidate the client's perception, which may cause defensiveness or resistance. The PN should avoid arguing or disagreeing with the client about their hallucinations, as this may damage the therapeutic relationship. The PN should acknowledge and accept the client's experience without endorsing or reinforcing it.
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