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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Implementing fall precautions is the most important intervention for a client with Parkinson’s disease experiencing decreased postural reflexes, rigidity, and gait issues. These symptoms significantly increase the risk of falls, so fall precautions are crucial for preventing injury.
B. Aspiration precautions are important for many clients, but they are less immediately relevant in this context compared to fall prevention. The symptoms listed do not directly indicate a high risk of aspiration.
C. Reorientation cues may be necessary for clients with cognitive issues but are not the primary concern for managing motor symptoms like those listed. The focus here should be on physical safety rather than cognitive orientation.
D. Bowel training is a useful intervention for managing bowel function but is not directly related to the acute risks of fall and gait disturbances associated with Parkinson’s disease.
Correct Answer is B
Explanation
A. Elevated blood glucose is not typically associated with Cheyne-Stokes respirations. It might indicate diabetes or hyperglycemia but does not relate to this specific pattern of breathing.
B. Cheyne-Stokes respirations are often observed when death is imminent or in severe cases of terminal illness. This breathing pattern is characterized by cycles of increasing and decreasing respirations, often seen in end-of-life care.
C. An allergic reaction might cause respiratory symptoms, but it is not specifically associated with Cheyne-Stokes respirations. Assessing for Cheyne-Stokes would be more relevant in terminal or serious conditions rather than acute allergic reactions.
D. Cheyne-Stokes respirations are not related to strenuous exercise. After exercise, normal changes in breathing patterns occur, but Cheyne-Stokes respirations are indicative of more severe conditions.
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