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
Trousseau’s sign is a test for hypocalcemia that involves inflating a blood pressure cuff on the arm and observing for carpal spasm. A positive sign indicates low calcium levels in the blood, which can cause neuromuscular irritability.
Choice B is wrong because hyperactive deep tendon reflexes are a sign of hypomagnesemia, which is a low level of magnesium in the blood.
Choice C is wrong because hyperactive bowel sounds are a sign of hyperkalemia, which is a high level of potassium in the blood.
Choice D is wrong because muscle twitching can be caused by many factors, such as anxiety, caffeine, or electrolyte imbalance, and is not specific to hypocalcemia.
Correct Answer is ["B","C","D"]
Explanation
Hypercalcemia is a condition in which the calcium level in the blood is above normal.
This can cause various symptoms, such as confusion, constipation, and bradycardia (slow heart rate).
These are the clinical manifestations that the nurse would expect to observe in a client with hypercalcemia.
Choice A is wrong because muscle spasms are not a common symptom of hypercalcemia.
In fact, hypercalcemia can cause muscle weakness and pain.
Choice E is wrong because polyuria (excessive urination) is not a direct symptom of hypercalcemia, but rather a result of kidney problems caused by hypercalcemia.
Hypercalcemia can make the kidneys work harder to filter the excess calcium, leading to dehydration and thirst.
However, this does not necessarily mean that the client will have polyuria.
Normal ranges for calcium levels in the blood are 8.5 to 10.2 mg/dL (milligrams per deciliter) or 2.1 to 2.6 mmol/L (millimoles per liter).
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