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 ["B","D"]
Explanation
Choice A rationale: Orange juice contains pulp and is not considered a clear liquid. A clear liquid diet is restricted to fat-free liquids and those that are transparent at room temperature.
Choice B rationale: Apple juice is a transparent liquid that remains liquid at room temperature. It provides carbohydrates and fluid without leaving residue in the gastrointestinal tract, fitting the clear liquid requirement.
Choice C rationale: Hot chocolate contains dairy or cocoa solids, making it an opaque liquid. It is excluded from a clear liquid diet and also contains caffeine, which Mormons typically avoid.
Choice D rationale: Chicken broth is a clear, fat-free liquid that provides electrolytes and hydration. It is an essential component of a clear liquid diet and does not violate any Mormon dietary restrictions.
Choice E rationale: Black coffee is a caffeinated beverage. The Word of Wisdom in Mormon belief prohibits the consumption of "hot drinks," specifically interpreted as coffee and tea, regardless of the diet type.
Correct Answer is C
Explanation
The correct answer is choicec. Administer prescribed stool softener.
Choice A rationale:
Administering prescribed PRN sleep medications can help the client rest, but it is not the highest priority. Managing pain and preventing complications from the laceration are more critical.
Choice B rationale:
Encouraging the use of prescribed analgesic perineal sprays can help manage pain and promote healing, but it is not as crucial as preventing constipation, which can cause significant discomfort and complications.
Choice C rationale:
Administering prescribed stool softeners is the highest priority because a fourth-degree laceration involves the anal sphincter and rectal mucosa.Preventing constipation is essential to avoid straining during bowel movements, which can cause pain and disrupt the healing process.
Choice D rationale:
Encouraging breastfeeding to promote uterine involution is important for postpartum recovery, but it is not directly related to the care of a fourth-degree laceration. Managing pain and preventing complications from the laceration take precedence.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.