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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Provide only distilled water. Providing only distilled water is not appropriate in this situation.
The client's weight gain and electrolyte imbalance indicate the need for careful monitoring and intervention, but restricting fluid intake to distilled water alone may not address the underlying issues adequately.
B. Document abdominal girth. Documenting abdominal girth is important to assess for signs of ascites, which can occur in hepatic failure. A sudden weight gain and elevated blood pressure may indicate fluid retention, and documenting abdominal girth can provide additional information about fluid accumulation in the abdomen.
C. Offer a high protein diet. While nutritional support is important for clients with hepatic failure, offering a high protein diet may not be appropriate if the client has an electrolyte imbalance. Protein intake should be balanced and monitored carefully to avoid exacerbating the imbalance.
D. Use a cushion when sitting. Using a cushion when sitting may be beneficial for comfort, but it does not directly address the identified issues of electrolyte imbalance, elevated blood pressure, and weight gain. The priority is to assess and address these concerns through appropriate
interventions such as documenting abdominal girth and addressing fluid retention.

A. Lymphangitis. B. Malignancy. C. Viral Infection. D. Bacterial Infection.

Correct Answer is B

Explanation

A. Lymphangitis is characterized by inflammation of the lymphatic vessels and is often associated with red streaks and tenderness. The absence of inflammation and tenderness suggests a different etiology.

B. Malignancy is suggested by the presence of a large, nontender, hardened lymph node. These characteristics are commonly associated with metastatic spread of cancer to the lymph nodes. Further diagnostic testing, such as biopsy, would be warranted to confirm malignancy.

C. Viral infection may cause lymphadenopathy, but typically, the lymph nodes are tender and may be enlarged but not necessarily hardened. The absence of tenderness and the hardened consistency of the lymph node suggest a different etiology.

D. Bacterial infection can cause lymphadenopathy, which may be tender and enlarged, but the nontender, hardened nature of the lymph node in this case is more indicative of malignancy
rather than a bacterial infection.

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Prior to insertion of an indwelling urinary catheter, which client information is most important for the nurse to obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse identifies an electrolyte imbalance, an elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with hepatic failure. Which intervention should the nurse include in the plan of care?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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