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 A

Explanation

A. Reporting the findings to the healthcare provider is crucial in this situation. The combination of fever and dyspnea could indicate a serious complication such as aspiration pneumonia or an infection related to the tube feeding. Prompt communication with the healthcare provider ensures that the client receives timely evaluation and treatment.
B. While monitoring electrolytes is important in the context of tube feedings (to ensure proper balance and prevent imbalances), the symptoms of fever and dyspnea are more urgent concerns that need immediate attention.
C. Using an incentive spirometer can be beneficial for improving lung function and preventing complications like atelectasis, especially if the client has respiratory issues. However, this action is more appropriate for clients who have specific respiratory therapy needs and is not the first step in addressing acute symptoms like fever and dyspnea, which require a more immediate response.
D. Connecting the tube to low intermittent suction might be used to manage gastric residuals or to help with gastrointestinal decompression in some situations, but it does not address the acute symptoms of fever and dyspnea.

A. Record the client's ability to perform ADLs safely. B. Initiate a fall risk protocol for the client. C. Teach the client to shorten the stride to prevent falls. D. Determine the client's activity tolerance.

Correct Answer is A

Explanation

A. This action is appropriate given that the client’s posture is upright and their gait is smooth and steady. If the client demonstrates safe ambulation and is capable of performing ADLs effectively, documenting this observation is crucial for maintaining a record of their functional status.
B. Initiating a fall risk protocol may not be immediately necessary if the client shows a smooth, steady gait and upright posture. However, fall risk assessments are generally based on multiple factors, including history of falls, medication side effects, and environmental hazards.
C. The client’s smooth and steady gait suggests they are ambulating effectively. Teaching the client to shorten their stride is typically advised when there is observed instability or an increased risk of falls.
D. Assessing the client's activity tolerance is a valid consideration, but it may not be the immediate next step if the client’s gait and posture are already observed to be steady and upright.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has a continuous tube feeding develops a fever and reports experiencing dyspnea. Which action should the nurse implement?

Correct Answer is A

Explanation

The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

Correct Answer is A

Explanation

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