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 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.

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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.

A. Hand tremors. B. Shuffling gait. C. Urinary incontinence. D. Diminished visual acuity. E. Syncope when bending.

Correct Answer is ["A","B","D"]

Explanation

A. Hand tremors can impair the client’s ability to safely and effectively perform fine motor tasks, such as toenail care, making it necessary to assign a UAP for this task.
B. A shuffling gait suggests a mobility issue, which may make it difficult for the client to safely bend over and care for their feet, increasing the risk of falls or improper foot care.
C. Urinary incontinence does not directly impact the client’s ability to perform foot care and is not a reason to assign a UAP for this task.
D. Diminished visual acuity affects the client’s ability to see clearly, which is crucial when performing tasks like toenail care to avoid injury.
E. Syncope when bending indicates a risk of fainting, but it is not specifically related to the need for routine foot care by a UAP.

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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?

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Naxlex Comprehensive Predictor Exams

The healthcare provider gives a verbal prescription for 2 mg of intravenous morphine to be given to a client every 4 hours as needed for severe pain. How should the nurse document the prescription?

Correct Answer is B

Explanation

The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and file the client's toenails? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

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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?

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