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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Reporting the 24-hour intake at the current infusion rate is not the most important finding to report to the healthcare provider in this case. It is essential to monitor intake and output, but a single report of the 24-hour intake is not as critical as other findings.

Choice B rationale:

Reporting a serum potassium level of 3.1 mEq/L (3.1 mmol/L) is the most important finding to report to the healthcare provider. The patient's potassium level is below the normal range, indicating hypokalemia. Hypokalemia can have serious cardiac and neuromuscular effects, including arrhythmias and muscle weakness. Prompt intervention, such as potassium supplementation or adjustment of IV fluids, is necessary to address this potentially life-threatening condition.

Choice C rationale:

Reporting a gastric output of 900 mL in the last 24 hours is significant and should be reported to the healthcare provider, but it is not as urgent as the low potassium level. Gastric output should be monitored to assess for signs of improvement or worsening, but hypokalemia takes precedence due to its immediate health risks.

Choice D rationale:

Reporting an increased blood urea nitrogen (BUN) is important for the overall assessment of the patient's renal function but is not the most critical finding in this scenario. The low potassium level is a more immediate concern and requires immediate attention.

A. Instruct the unlicensed assistive personnel (UAP) to apply a warm blanket and massage the client's back. B. Insert a gloved finger into the rectum and gently massage the rectal sphincter. C. Stop the procedure and observe for a reduction in symptoms before continuing. D. Encourage the client to take slow, deep breaths while continuing the procedure. E. Encourage the client to take slow, deep breaths while continuing the procedure.

Correct Answer is A

Explanation

Choice A rationale:

Instructing the UAP to apply a warm blanket and massage the client's back is the appropriate intervention in response to the client's complaints of feeling dizzy and cold during a fecal impaction removal procedure. These symptoms suggest a vasovagal response, which can be managed by keeping the client warm and providing comfort. This intervention helps increase blood flow and alleviate symptoms.

Choice B rationale:

Inserting a gloved finger into the rectum and massaging the rectal sphincter is not the first-line intervention when a client complains of feeling dizzy and cold during a fecal impaction removal. This invasive procedure should be reserved for cases where other interventions have failed, and it is necessary to complete the impaction removal.

Choice C rationale:

Stopping the procedure and observing for a reduction in symptoms before continuing is a reasonable approach, but it does not address the immediate discomfort and distress the client is experiencing. Providing comfort measures, such as applying a warm blanket and massaging the client's back, should be the initial response.

Choice D rationale:

Encouraging the client to take slow, deep breaths while continuing the procedure may not be effective in addressing the client's symptoms of dizziness and coldness. The client may require immediate comfort measures to stabilize their condition.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

During a fecal impaction removal, an older client complains of feeling dizzy and cold. Which intervention should the nurse implement?

Correct Answer is A

Explanation

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