The nurse is assessing a patient with a urinary catheter.
Which of the following would be a priority nursing intervention?
Removing the catheter as soon as possible to prevent infection.
Ensuring that the catheter is properly secured to prevent accidental dislodgement.
Encouraging the patient to drink fluids to prevent dehydration.
Administering antibiotics to prevent infection.
Administering antibiotics to prevent infection.
The Correct Answer is A
This is because urinary catheters are a common source of catheter associated urinary tract infections (CAUTIs), which can lead to complications such as pyelonephritis, sepsis, and renal failure. Therefore, the nurse should remove the catheter as soon as possible to reduce the risk of infection and promote normal urinary function.
Choice B is wrong because ensuring that the catheter is properly secured to prevent accidental dislodgement is not a priority intervention for a patient with a urinary catheter.
While this is an important nursing action to prevent trauma and bleeding, it does not address the main complication of catheterization, which is infection.
Choice C is wrong because encouraging the patient to drink fluids to prevent dehydration is not a priority intervention for a patient with a urinary catheter.
While this is a good nursing practice to maintain hydration and renal perfusion, it does not affect the risk of infection associated with catheterization.
Choice D is wrong because administering antibiotics to prevent infection is not a priority intervention for a patient with a urinary catheter.
While this may be indicated for some patients who have signs and symptoms of UTI or who are at high risk of infection, it is not a routine measure for all patients with catheters and may contribute to antibiotic resistance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Sodium is the major extracellular electrolyte in the body.
It is responsible for maintaining the extracellular fluid volume, and also for regulation of the membrane potential of cells.
Sodium is exchanged along with potassium across cell membranes as part of active transport.
Choice B is wrong because potassium is mainly an intracellular ion.
It is important for nerve and muscle function, but it is not the predominant electrolyte in the extracellular fluid.
Choice C is wrong because calcium is not the major electrolyte in the extracellular fluid.
Calcium is mostly found in bones and teeth, where it forms a mineral reserve with phosphate.
Calcium also plays a role in muscle contraction, blood clotting, and enzyme activity.
Choice D is wrong because magnesium is not the major electrolyte in the extracellular fluid.
Magnesium is mostly found in bones, where it helps to stabilize the structure of ATP2.
Magnesium also participates in enzyme reactions, nerve and muscle function, and protein synthesis.
Correct Answer is C
Explanation
A urinary tract infection (UTI) is a common complication after bladder cancer surgery, especially if the patient has an indwelling urinary catheter.
A UTI can cause symptoms such as fever, pain, burning or urgency when urinating, blood in the urine, or cloudy or foul-smelling urine.
Choice A is wrong because urinary retention (the inability to empty the bladder completely) is unlikely to occur with an indwelling catheter, which drains urine continuously.
Choice B is wrong because urinary incontinence (the loss of bladder control) is more likely to occur after partial or radical cystectomy, which remove part or all of the bladder, respectively.
In these cases, reconstructive surgery is needed to create a new way for urine to leave the body.
Choice D is wrong because urinary urgency (the sudden and strong need to urinate) is also more likely to occur after partial or radical cystectomy, which can affect the nerves and muscles that control urination.
Urinary urgency can also be a symptom of a UTI, but it’s not the only one.
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