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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Correct Answer is D

Explanation

A. Positioning the client in a lateral lying position might help with comfort but does not address the immediate concern of the low blood pressure.
B. Documenting the blood pressure and monitoring the client is important, but it does not address the need to prevent potential adverse effects from administering the medication at such a low blood pressure.
C. Encouraging an increase in oral fluid intake may be helpful in managing blood pressure, but the immediate priority should be to address the potential effects of the medication on the low blood pressure.
D. Holding the medication and notifying the healthcare provider is the appropriate action because administering the medication with a blood pressure of 80/50 mm Hg could worsen hypotension and lead to further complications. The healthcare provider should be informed to reassess the medication plan.

Correct Answer is ["20"]

Explanation

To calculate the total daily dose, we first need to determine the dose per administration:

Desired dose = 200 mg/dose
Concentration = 100 mg/5 mL

Volume (mL) = Desired dose (mg) / Concentration (mg/mL)

Volume = 200 mg / (100 mg/5 mL) = 10 mL

Now, calculate the total daily volume:

10 mL/dose 2 doses/day = 20 mL/day

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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

The healthcare provider prescribes two doses of an antihypertensive medication for a client. Before administering the second dose, the nurse obtains a blood pressure measurement of 80/50 mm Hg. Which action should the nurse take?

Correct Answer is D

Explanation

The healthcare provider prescribes cefixime oral suspension 200 mg by mouth twice a day for an older adult who has difficulty swallowing pills. The bottle is labeled, "Cefixime for Oral Suspension, USP 100 mg per 5 mL." How many mL should the nurse administer daily? (Enter numerical value only.)

Correct Answer is ["20"]

Explanation

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