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
The correct answer is A. 42 mL/h.
Choice A: 42 mL/h
Reason: To calculate the IV rate, we use the formula: IV rate (mL/h) = Total volume (mL) ÷ Total time (hours). For this problem, the total volume is 1000 mL and the total time is 24 hours. Therefore, the calculation is 1000 mL ÷ 24 hours = 41.6667 mL/h. When rounded to the nearest whole number, the IV rate is 42 mL/h. This makes 42 mL/h the correct answer.
Choice B: 44 mL/h
Reason: This choice is incorrect because it does not match the calculated IV rate. The calculation of 1000 mL ÷ 24 hours results in 41.6667 mL/h, which rounds to 42 mL/h, not 44 mL/h. Therefore, 44 mL/h is not a valid option based on the given data.
Choice C: 46 mL/h
Reason: This choice is also incorrect. The calculated IV rate of 41.6667 mL/h, when rounded to the nearest whole number, is 42 mL/h. There is no mathematical basis for rounding up to 46 mL/h from 41.6667 mL/h, making this choice invalid.
Choice D: 48 mL/h
Reason: This choice is incorrect as well. The correct calculation yields 41.6667 mL/h, which rounds to 42 mL/h. There is no justification for rounding up to 48 mL/h. This choice does not align with the calculated and rounded IV rate.
Correct Answer is A
Explanation
Increased urine output is a sign of adequate hydration, as it means the kidneys are filtering waste and fluids from the body through the urine. The urine should be pale straw or lemonade colored, which indicates good hydration.
Choice B is wrong because decreased urine output is a sign of dehydration, as it means the kidneys are not working well and waste products are accumulating in the blood.
The urine may be dark and strong smelling, which indicates poor hydration.
Choice C is wrong because dry mucous membranes are a sign of dehydration, as they indicate a lack of fluid in the body tissues.
Choice D is wrong because hypertension is not a direct indicator of hydration status, although dehydration can cause low BP due to reduced blood volume.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today