While inserting an indwelling urinary catheter into a female client, the nurse observes urine flow in the tubing. Which action should be taken next?

Document the color and clarity of the urine.

Inflate the balloon with 5 mL of sterile water.

Ask the client to breathe deeply and slowly exhale.

Insert the catheter an additional inch.

Answer and Explanation

The Correct Answer is B

A.   While documenting the color and clarity of the urine is important for assessing the client's urinary output and potential issues, it is not the immediate next step in the catheter insertion process. This step typically comes after the catheter is fully inserted and secured.
B.   Once urine flow is observed, the next step is to inflate the balloon of the indwelling catheter to secure it in place within the bladder. This ensures the catheter remains correctly positioned and does not move out of the bladder, which is crucial for effective drainage and preventing accidental dislodgement.
C.   Asking the client to breathe deeply and exhale does not impact the catheterization process and is not related to the next immediate step after observing urine flow. This action might be helpful in other contexts, such as reducing anxiety or discomfort, but it does not address the technical steps required for catheter insertion.
D.   If urine flow is observed in the catheter, it indicates that the catheter is already in the bladder. Inserting the catheter an additional inch is unnecessary and could potentially cause trauma or discomfort. Proper catheter placement is confirmed by the observation of urine flow, and additional insertion is not required.

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Correct Answer is D

Explanation

A. Increasing dietary fiber and adding prune juice can help relieve constipation by improving bowel regularity. While this is an important step in managing constipation, it is not the first action to take without understanding the underlying cause or current status of bowel function.
B. Physical activity is important for bowel regularity, especially post-surgery. However, assessing physical activity should come after a more immediate evaluation of the client's bowel status. It is crucial to first determine if there are other underlying issues that need addressing before implementing dietary changes or increasing activity.
C. A digital examination can be necessary to identify fecal impaction, especially if other assessments suggest severe constipation or if the client has not had a bowel movement for several days. However, this is an invasive procedure and should be performed based on preliminary findings from non-invasive assessments.
D. Checking bowel sounds and abdominal tenderness is an essential first step in assessing the client's gastrointestinal status. It helps identify whether there is a lack of bowel movement due to a more severe issue such as bowel obstruction or if it is simply a case of constipation.

A. Place client on her left side while delivering the bolus. B. Ask the client to select a preferred flavor for the bolus. C. Elevate head of bed 30 degrees for 1 hour after bolus. D. Flush tubing with warm water before and after bolus. E. Include amount of feeding when recording fluid Intake.

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

Explanation

A. Placing the client on her left side is not a standard practice for delivering enteral feedings. Generally, the client should be in a semi-Fowler’s position (head of bed elevated at 30-45 degrees) to minimize the risk of aspiration and aid in digestion.
B. While asking for a preferred flavor may be appropriate for improving patient comfort and adherence to the feeding regimen, it is not always feasible or necessary, particularly if the client has limited ability to communicate or make choices.
C. Elevating the head of the bed to 30 degrees for 1 hour after administering a bolus feeding helps to reduce the risk of aspiration and aids in digestion by allowing gravity to assist in moving the feeding into the stomach. This is a standard practice for patients receiving enteral feedings and is important for preventing complications like aspiration pneumonia.
D. Flushing the tubing with warm water before and after administering the bolus is essential to ensure that the entire amount of feeding is delivered and to prevent clogging of the tube. This practice helps in maintaining tube patency and ensuring that the client receives the full intended dose of nutrition.
E. It is important to record the amount of enteral feeding as part of the client’s total fluid intake. Accurate documentation helps in monitoring the client’s fluid balance and nutritional intake, which is critical for managing the client’s overall health and adjusting their care plan as needed.

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While inserting an indwelling urinary catheter into a female client, the nurse observes urine flow in the tubing. Which action should be taken next?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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

Explanation

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