The practical nurse (PN) is assisting with preparation of a client for fecal diversion surgery. While inserting an indwelling urinary catheter, the client asks if the surgical opening will be visible. Which action should the PN implement?
Ask the client if he finished the bowel sterilization prescription.
Review the client's expectations of elimination after surgery.
Verify that the client had nothing by mouth (NPO) for the past 24 hours.
Determine if this is the first indwelling catheter the client has had.
The Correct Answer is B
A. Asking about the bowel sterilization prescription doesn't address the client's concern regarding the visibility of the surgical opening.
B. Reviewing the client's expectations after surgery could address the client's query about the visibility of the surgical opening and offer information regarding elimination.
C. Verifying the NPO status is important for surgery preparation but doesn’t directly address the client's specific concern.
D. Determining if this is the first indwelling catheter doesn’t directly address the client's immediate concern regarding the surgical opening.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This statement shows awareness but doesn't necessarily indicate acceptance of the prognosis. B. Acceptance is often linked with finding emotional support, and this statement implies the client has found solace and support from faith and family, reflecting a level of acceptance. C. This statement suggests a disbelief or denial of the diagnosis, which is not indicative of acceptance.
D. This statement reflects resistance and denial rather than acceptance of the prognosis. Acceptance usually involves acknowledgment and finding ways to cope positively, which is not shown in this statement.
Correct Answer is ["B","C","D"]
Explanation
A. Irrigate an indwelling urinary catheter for a client with bladder suspension. - This procedure requires specialized skills and should be performed by a licensed nurse.
B. Empty bedside drainage unit for a client with an indwelling urinary catheter. - UAP can safely perform this task by following established protocols to maintain catheter hygiene.
C. Transport a urine culture sample to the laboratory. - This task involves safely transporting a specimen and does not require specialized medical knowledge.
D. Obtain a post-voided residual (PVR) volume. - This task can be performed by UAP under supervision or with appropriate training, using a bladder scanner or assisting the client to measure remaining urine.
E. Teach the client with fluid restrictions how to measure urine output. - Teaching tasks generally fall under the responsibility of licensed nursing staff and may require specific medical knowledge.
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