Nokea
The client with an indwelling urinary catheter requires discharge teaching. Which interventions should the nurse include in the teaching plan? Select all that apply.
- A. Plan to change the urinary catheter once a week.
- B. Cleanse the perineal area daily with soap and water.
- C. Secure the catheter tubing to the thigh with tape.
- D. Avoid showering while the catheter is in place.
- E. Perform hand hygiene before and after catheter care.
Correct Answer: B,C,E
Rationale: B: Daily cleansing with soap and water prevents infection. C: Securing the catheter reduces trauma. E: Hand hygiene minimizes infection risk. A: Monthly changes are recommended unless blockage occurs. D: Showering is safe if the client's condition allows.
You may also like to solve these questions
The intent of the Patient Self Determination Act (PSDA) of 1990 is to:
- A. enhance personal control over legal care decisions
- B. encourage medical treatment decision making prior to need
- C. give one federal standard for living wills and durable powers of attorney
- D. emphasize client education
Correct Answer: B
Rationale: The PSDA encourages advance directives to promote proactive medical decision-making, ensuring clients' wishes are honored before a crisis.
A 17-year-old female was raped by a young man in her neighborhood. She is in the Emergency Department for evaluation and tests. After the procedure is completed, a rape crisis counselor (nurse specialist) talks to the client in a conference room regarding the rape. Implementing counseling by the nurse specialist for the raped victim represents:
- A. assessment.
- B. crisis intervention.
- C. empathetic concern.
- D. unwarranted intrusion.
Correct Answer: B
Rationale: Choice 2 is part of the Crisis Intervention Model. Counseling by a nurse specialist at the time of a stressful event (rape) can strengthen the client's coping. A nurse specialist in rape crisis intervention is educationally prepared in counseling and crisis intervention specific to rape victims.
Distraction therapy is:
- A. Focusing one's attention on stimuli other than pain
- B. Cognitive reappraisal
- C. The replacement of positive images of pain with other images
- D. The use of medication and meditation
Correct Answer: A
Rationale: The focus of distraction therapy is on positive stimuli rather than negative input, helping to manage pain perception.
Nurses caring for clients who have cancer and are taking opioids need to assess for all of the following except:
- A. tolerance.
- B. constipation.
- C. sedation.
- D. addiction.
Correct Answer: D
Rationale: Addiction is not of primary concern when treating the pain of terminally ill clients. Clients with cancer who are taking opioid analgesics can develop tolerance, constipation, and sedation.
A client is to have an enema to reduce flatus. The enema tube should be inserted:
- A. 4 inches.
- B. 6 inches.
- C. 2 inches.
- D. 8 inches.
Correct Answer: A
Rationale: Enema tubing must be passed beyond the internal sphincter. Two inches is not far enough to pass the internal sphincter. Both 6 and 8 inches are too far and might cause trauma to the bowel.