Prior to insertion of an indwelling urinary catheter, which client information is most important for the nurse to obtain?
Previous history of urinary tract infections.
Client's ability to increase fluid intake.
Client allergies to antiseptic solutions.
Color, clarity, and odor of urine.
The Correct Answer is C
A. While a history of urinary tract infections is important to know for overall assessment and planning of care, it may not directly affect the decision to insert a urinary catheter unless there are specific concerns related to infection prevention.
B. The client's ability to increase fluid intake may be relevant to their overall hydration status and urinary function but is not directly related to the insertion of an indwelling urinary catheter.
C. This is the most important information to obtain because the nurse needs to ensure that the client does not have any allergies to antiseptic solutions that may be used during the catheter insertion procedure to prevent infection.
D. While the color, clarity, and odor of urine are important indicators of urinary health, they are not the most critical information to obtain prior to catheter insertion. However, assessing urine characteristics is important for ongoing monitoring of urinary function and potential
complications post-insertion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Gained 10 lb (4.5 kg) within one month. Weight gain is not typically associated with the onset of type 1 diabetes. In fact, weight loss is more common due to the body's inability to use glucose properly.
B. Drinks more fluids than previously. Increased thirst (polydipsia) is a classic symptom of type 1 diabetes due to high blood sugar levels causing dehydration.
C. Voids only one or two times per day. Increased urination (polyuria) is a common symptom of type 1 diabetes as the body attempts to excrete excess glucose, so decreased urination is unlikely.
D. Refuses to eat favorite meals at home. While changes in appetite can occur, it is not a primary symptom of type 1 diabetes. Increased hunger (polyphagia) is more typical.
Correct Answer is []
Explanation
- Potential Condition:
Stage 2 pressure injury
- Actions to Take:
C. Clean the area and dry carefully: Proper wound care involves cleaning the area to prevent infection and promote healing. Cleaning the erythematous area on the left heel and ensuring
it is dry can help prevent further skin breakdown and promote healing.
B. Hold the hydrochlorothiazide: Hydrochlorothiazide is a diuretic that can increase urine output and potentially lead to dehydration, which may exacerbate the client's condition. Holding the medication temporarily can help prevent further fluid loss and dehydration, which is crucial for wound healing.
- Parameters to Monitor:
B. Skin color: Monitoring the skin color around the erythematous area on the left heel can help assess tissue perfusion and identify any signs of deterioration or improvement in the wound condition.
D. Fluid balance: Monitoring the client's fluid balance, including intake and output, is essential for assessing hydration status and ensuring adequate tissue perfusion, which is vital for wound healing and overall patient well-being.
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