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 A

Explanation

A. Paper masks and gowns used for isolation precautions should be placed in a designated biohazard bag before removal from the room. These items are considered contaminated and must be disposed of according to infection control protocols.
B. A sputum specimen should be placed in a sealed, labeled container before being transported to the lab, not in a biohazard bag for disposal.
C. The nurse's stethoscope should be disinfected but does not need to be disposed of unless it is single-use.
D. Bed linens are typically placed in a laundry bag specifically designated for contaminated linens, not in a biohazard bag.

A. Instruct the client to use guided imagery and slow rhythmic breathing. B. Place a hot water circulation device, such as an Aqua K pad, to the operative site. C. Tune to a television show or easy listening music to provide distraction. D. Provide at least 20 minutes of back massage and gentle effleurage.

Correct Answer is A

Explanation

A. Guided imagery and slow rhythmic breathing are effective techniques for managing moderate pain and can help reduce the perception of pain by promoting relaxation. These methods can be used in conjunction with pain medication to enhance overall pain management.
B. Applying a hot water circulation device may not be appropriate for postoperative pain, as heat could interfere with healing or cause complications. The focus should be on pain management strategies that are safe for the surgical site.
C. While distraction methods like television or music can help, they are generally less effective for managing moderate pain compared to relaxation techniques and additional pain management strategies.
D. Providing a back massage may not be appropriate immediately after thoracic surgery, as it could cause discomfort or interfere with the surgical site. Effective pain management should prioritize safe and recommended interventions.

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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

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Explanation

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Explanation

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