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.
The Correct Answer is B
A. Power flushing with 60 mL might be too forceful and could potentially damage the bladder or catheter. It is important to use a gentle approach to avoid complications.
B. Slowly irrigating the catheter with saline using an infusion pump is appropriate for gently clearing the clots and sediment while maintaining a controlled flow rate. This method is effective in managing obstructions and maintaining catheter patency.
C. Clamping the catheter before irrigation is not recommended as it could lead to increased bladder pressure and discomfort. The goal is to maintain urine flow and prevent complications from clots.
D. Using a sterile syringe to irrigate with 20 mL normal saline may not be sufficient to clear larger clots and sediment. A controlled, slower irrigation method using an infusion pump is generally preferred.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Developing a plan for increasing activity and mobility is important but is not the immediate priority during the prodromal stage of an infection.
B. Discharge planning and teaching are relevant for patient management but not the priority during the early stages of infection.
C. Implementing precautions to prevent disease transmission is crucial during the prodromal stage, as this is when the infection may be most contagious. Preventing the spread of infection is the top priority.
D. Offering fluids and ice chips helps with comfort and hydration but does not address the prevention of disease transmission.
Correct Answer is ["0.8"]
Explanation
To calculate the volume of hydromorphone to administer, we can use the following formula:
Volume (mL) = Dose (mg) / Concentration (mg/mL)
In this case:
- Dose = 3 mg
- Concentration = 4 mg/mL
Plugging in the values:
Volume (mL) = 3 mg / 4 mg/mL = 0.75 mL
Therefore, the nurse should administer 0.8 mL of hydromorphone to the client.
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