The practical nurse (PN) is documenting the insertion of a urinary catheter for a female client with urinary retention. What information should the PN include during the electronic documentation of the procedure? Select all that apply.

Client positioning during procedure.

Amount of lubricant used.

Size of urinary catheter.

Appearance of urine obtained.

Amount of urine obtained.

Answer and Explanation

Correct Answer : A,C,D

A. Client positioning during the procedure should be documented to ensure that the procedure was performed correctly and that the client was appropriately positioned for catheter insertion.
B. The amount of lubricant used is not a standard detail for documenting catheter insertion. Documentation focuses on the procedure's outcomes and specific technical details rather than quantities of materials used.
C. The size of the urinary catheter should be documented as it is a critical detail for future reference and to ensure that the catheter was appropriate for the client’s needs.
D. The appearance of the urine obtained should be documented as it provides important information about the client’s urinary status and can indicate potential issues like infection or hematuria.
E. While the amount of urine obtained might be relevant for assessing urinary retention, it is not a standard part of the initial documentation for catheter insertion unless there was a significant volume change or specific concern.

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Correct Answer is B

Explanation

A. Exhaling slowly after two seconds is not part of the incentive spirometer use. Proper technique involves a slow, steady inhalation, not exhalation.
B. Blowing forcefully into the mouthpiece indicates incorrect use of the spirometer. The client should inhale slowly and deeply through the mouthpiece to expand the lungs and improve ventilation.
C. Using a tight seal around the mouthpiece is correct and necessary to ensure that the spirometer measures the volume of air accurately.
D. Sitting upright during the treatment is correct as it maximizes lung expansion and facilitates deep breathing.

A. Skin turgor. B. Body weight. C. Temperature. D. Blood pressure.

Correct Answer is D

Explanation

A. Skin turgor is important for assessing hydration status, but it is not the most critical factor when preparing for a safe transfer. For an unresponsive client, ensuring stable hemodynamic conditions is more urgent. Blood pressure provides essential information about the client’s circulatory status, which is crucial for assessing the risks associated with the transfer.
B. Body weight is generally used for dosing medications or assessing nutritional status and is not immediately relevant for ensuring a safe transfer of an unresponsive client. Although body weight might be useful in planning the transfer logistics, it does not impact immediate safety concerns.
C. Temperature can indicate infection or other issues but does not directly affect the immediate safety of the transfer process. While monitoring temperature is part of overall care, it is not the most pressing concern during the transfer.
D. Blood pressure is essential to check before the transfer because it reflects the client’s cardiovascular stability. Low or unstable blood pressure might increase the risk of complications during the transfer, such as a sudden drop in blood pressure that could lead to a fall or injury.

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The practical nurse (PN) is documenting the insertion of a urinary catheter for a female client with urinary retention. What information should the PN include during the electronic documentation of the procedure? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is using an incentive spirometer on the first postoperative day after an inguinal herniorrhaphy. The practical nurse (PN) should reteach the proper use of the spirometer when the client demonstrates which action?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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