The nurse is preparing a bladder irrigation for an adult client who has a long-term indwelling urinary catheter. The urine is cloudy with fibrin clots and sediment. Which intervention should the nurse implement?

Power flush with 60 mL to remove mucous obstructions.

Slowly irrigate catheter with saline using an infusion pump.

Clamp the catheter for 30 minutes prior to irrigating.

Use a sterile syringe to irrigate with 20 mL normal saline.

Answer and Explanation

The Correct Answer is D

A. Power flushing with 60 mL of solution can create excessive pressure in the bladder, increasing the risk of trauma or forcing bacteria into the urinary tract. Gentle irrigation is preferred to safely remove clots and sediment without causing injury.

B. Using an infusion pump to slowly irrigate the catheter may not allow proper control of pressure and volume, which can damage the bladder mucosa. Manual irrigation allows the nurse to assess resistance and stop if obstruction or discomfort occurs.

C. Clamping the catheter for 30 minutes before irrigation can increase bladder pressure and cause discomfort or potential reflux of urine into the kidneys. Routine pre-irrigation clamping is not recommended unless specifically ordered for retention management.

D. Using a sterile syringe with 20 mL of normal saline allows controlled, gentle irrigation to remove clots and sediment. Sterile technique reduces the risk of introducing pathogens, and the small volume minimizes bladder trauma while effectively clearing the catheter.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Suggesting a stool softener is appropriate as it helps to ease bowel movements and reduce straining, which can alleviate pain associated with hemorrhoids and help establish a regular bowel pattern.
B. Recommending a daily laxative may not be appropriate for long-term use and could potentially exacerbate the issue if overused. It is generally better to start with less invasive measures like stool softeners.
C. Obtaining a stool specimen may be necessary for diagnostic purposes but does not directly address the immediate concern of painful defecation due to hemorrhoids.
D. Discussing oral analgesic options might help with pain management, but it does not address the underlying issue of constipation and the need for a regular bowel pattern. Stool softeners are more directly related to resolving the constipation problem.

A. Morphine 2.0 mg IV every four hours for severe pain. B. Morphine 2 mg IV every 4 hr PRN for severe pain. C. IV MS 2 mg every 4 hr as needed for severe pain. D. IV MS 2.0 mg every 4 hours PRN for severe pain.

Correct Answer is B

Explanation

A. The use of "2.0 mg" is incorrect because trailing zeros can lead to dosage errors. The correct documentation should avoid trailing zeros to prevent misinterpretation.
B. "Morphine 2 mg IV every 4 hr PRN for severe pain" is the correct format. It uses the full name of the drug, avoids abbreviations that could be confused, and follows best practices for documenting as-needed (PRN) medications.
C. Using "MS" instead of "morphine" is not recommended because "MS" can be confused with magnesium sulfate or other medications. The full drug name should always be used.
D. Similar to option A, the use of "2.0 mg" includes a trailing zero, which should be avoided to reduce the risk of errors in medication administration.

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The nurse is preparing a bladder irrigation for an adult client who has a long-term indwelling urinary catheter. The urine is cloudy with fibrin clots and sediment. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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