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 A,B,C,D

Explanation

A. Exposing the left side of the chest is the first step to access the area where the apical pulse is assessed. This step ensures that the nurse has clear access to the chest for auscultation.

B. Locating the point of maximal impulse (PMI) is the next step once the chest is exposed. The PMI, typically located at the 5th intercostal space at the midclavicular line, is where the heart’s apex is closest to the chest wall.

C. Positioning the diaphragm of the stethoscope on the PMI is the step where the actual auscultation begins. The diaphragm is used to listen for heart sounds.

D. Listening for heart sounds at the PMI is the final step to assess the apical heart rate. This step completes the assessment by allowing the PN to count the heart rate and evaluate the rhythm.

A. Bring the client to sit in the nursing station. B. Administer a nighttime sedative. C. Direct the client to go back to bed. D. Engage the client to determine current needs.

Correct Answer is D

Explanation

A. Bringing the client to sit at the nursing station may not address the underlying cause of the wandering behavior and could be less effective in meeting the client’s immediate needs.
B. Administering a nighttime sedative is not a suitable solution for wandering behavior, as it may lead to adverse effects and does not address the root cause of the behavior.
C. Directing the client to go back to bed may not be effective, especially if the client is disoriented or confused. The approach should involve understanding and addressing the client's needs.
D. Engaging the client to determine current needs is the best approach, as it helps to understand the cause of the wandering and address it appropriately, such as providing comfort, reassurance, or addressing a specific need.

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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.

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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