The charge nurse brings a #18 urinary catheter with a 30 mL balloon to the practical nurse (PN) who is preparing to insert a catheter in a female client who weighs 50 kg. Which action should the PN take first?
Obtain a 30 mL syringe and a vial of sterile water.
Ask the client if she has previously been catheterized.
Consult with the charge nurse about the catheter.
Position the client and observe the urinary meatus.
The Correct Answer is C
This is the first action that the PN should take because the catheter size and balloon volume are inappropriate for the client. A #18 urinary catheter is too large for a female client who weighs 50 kg, and a 30 mL balloon may cause bladder trauma or discomfort. The PN should consult with the charge nurse and obtain a smaller catheter (such as #14 or #16) with a 10 mL balloon.
A. Obtaining a 30 mL syringe and a vial of sterile water is not the first action because it does not address the issue of the catheter size and balloon volume.
B. Asking the client if she has previously been catheterized is not the first action because it does not address the issue of the catheter size and balloon volume.
D. Positioning the client and observing the urinary meatus is not the first action because it does not address the issue of the catheter size and balloon volume.
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Related Questions
Correct Answer is B
Explanation
This is the action that the PN should emphasize for the client to take before self-administration of the nasal spray because it clears the nasal passages of mucus and debris and allows for better absorption of the medication. The PN should also instruct the client to shake the botle well, tilt the head slightly forward, insert the nozzle into one nostril, close the other nostril with a finger, and press the pump while inhaling gently.
Correct Answer is B
Explanation
The correct answer is choice B, Contact information for the client's next of kin. Choice A rationale:
Knowing the name of the funeral home to contact is not a priority during the admission assessment of a terminally ill client. While this information may eventually be necessary, the immediate focus should be on gathering essential medical and contact information.
Choice B rationale:
Collecting contact information for the client's next of kin is crucial during the admission assessment of a terminally ill client. In case of any emergencies or changes in the client's condition, the healthcare team needs to be able to reach the client's closest family member or legal representative promptly.
Choice C rationale:
Healthcare proxy documentation is essential for clients who have designated someone to make medical decisions on their behalf if they become incapacitated. While this information is significant, it may not be directly applicable to all terminally ill clients, as not all of them may have a designated healthcare proxy.
Choice D rationale:
Knowing the client's wishes regarding organ donation is important for ethical and legal reasons. However, it is not the most critical piece of information to collect during the initial admission assessment of a terminally ill client. Organ donation discussions can be sensitive and require a more appropriate time and setting. The focus during admission is on immediate medical needs and contact information for family or next of kin.
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