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","D","E"]

Explanation

A. Subdural hemorrhage
The head CT was negative for bleeding or edema, making a subdural hemorrhage unlikely.
B. Respiratory distress
Given the history of drowning and the current signs of respiratory acidosis (pH 7.31, PaCO2 51), the child is at high risk for respiratory complications, including distress.
C. Hyperthermia
Hyperthermia is not a typical immediate complication following drowning in cool water, and the current body temperature of the child is within the normal range.
D. Cerebral edema
Although the initial CT scan is negative for edema, secondary cerebral edema can develop hours after the incident, especially in cases of significant hypoxemia.
E. Acute asphyxia
The initial incident of drowning and the resultant hypoxemia (as indicated by abnormal blood gases) place the child at risk for complications related to acute asphyxia.
F. Hypertension
The child's blood pressure is currently within normal limits, and hypertension is not a common immediate complication following drowning.

A. Gloves B. N95 Mask C. Gown D. Surgical Mask E. Goggles

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

Explanation

A. Gloves
Gloves are essential when entering the room because MRSA (Methicillin-resistant Staphylococcus aureus) is a pathogen that can be transmitted through direct contact with contaminated surfaces or secretions. Gloves protect both the client and the PN from the spread of the infection and should be worn when touching the patient or surfaces/items in the room.
B. N95 Mask
An N95 mask is not required for MRSA infections unless there are concerns about airborne transmission, which is not typical for MRSA. MRSA transmission is primarily through direct or indirect contact rather than airborne routes, so an N95 mask is not necessary in this scenario.
C. Gown
A gown is required when there is a risk of contamination from the environment or the patient, especially with MRSA infections. It helps to protect the PN’s clothing and skin from coming into contact with any infectious materials from the surgical site.
D. Surgical Mask
A surgical mask is appropriate for MRSA to protect against droplets and to prevent the spread of infection. It is particularly useful if there is a risk of droplets from the patient or if the PN is performing procedures that might generate droplets.
E. Goggles
Goggles are not required for MRSA unless there is a specific risk of splash or spray that could potentially expose the PN’s eyes to infectious materials. In the context of a surgical site infection, goggles are not a standard part of the PPE unless additional procedures are being performed that involve splashes

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

Explanation

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