Nokea
Which interventions should the nurse perform when inserting an indwelling urinary catheter in order to maintain both the integrity of the catheter and the client's safety? Select all that apply.
- A. Use strict aseptic technique.
- B. Place the drainage bag lower than the bladder level.
- C. Inflate the balloon with 4 to 5 mL beyond its capacity.
- D. Swab the urinary catheter with sterile water before inserting.
- E. Advance the catheter 1 to 2 inches after urine appears in the tubing.
Correct Answer: A,B,E
Rationale: The nurse would use strict aseptic technique to insert the catheter. The drainage bag is placed lower than bladder level to ensure drainage, prevent retrograde flow of urine, and reduce the risk of infection. Advancing the catheter 1 to 2 inches beyond the point where the flow of urine is first noted is also good practice because this ensures that the catheter balloon is completely in the bladder before it is inflated. The nurse risks rupturing the catheter's balloon by overinflating it; therefore, the nurse inflates the balloon with the specified volume for the catheter because inflating the balloon with 4 to 5 mL beyond its capacity is unsafe. The urinary catheter is sterile, so it is inappropriate and unnecessary to swab it with sterile water before inserting.
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The nurse monitors a client who has been diagnosed with brain death as a result of a severe head injury and is a potential organ donor. Which client assessment data should indicate to the nurse that the standard of care as an organ donor has been maintained?
- A. Urine output: 100mL} / \mathrm{hr
- B. \mathrm{pH of arterial blood: 7.32
- C. Capillary refill: 5 seconds
- D. Blood pressure: 90 / 48mmHg
Correct Answer: A
Rationale: Urine output at 100mL per hour indicates adequate renal perfusion and indicates that care standards as an organ donor are maintained. Clinical indicators of care below the standard include a \mathrm{pH of 7.32, indicating acidosis; capillary refill at 5 seconds, which is too slow; and hypotension, indicating an inadequate cardiac output. Guidelines that may be used and are helpful in determining organ viability are the 'rule of 100s ' in which the systolic blood pressure is maintained at 100mmHg , urine output at 100mL per hour, heart rate at 100 beats per minute, and \mathrm{PaO}_2 at 100mmHg .
The nurse is assigned to care for a client with a diagnosis of preeclampsia. The nurse should plan to implement which action to provide a safe environment?
- A. Maintain fluid and sodium restrictions.
- B. Take the client's vital signs every 4 hours.
- C. Turn off the room lights and draw the window shades.
- D. Encourage visits from family and friends for psychosocial support.
Correct Answer: C
Rationale: Clients with preeclampsia are at risk of developing eclampsia (seizures). Bright lights and sudden loud noises may initiate seizures in this client. A woman with preeclampsia should be placed in a dimly lighted, quiet, private room. Clients with preeclampsia have decreased plasma volume, and adequate fluid and sodium intake is necessary to maintain fluid volume and tissue perfusion. Vital signs need to be monitored more frequently than every 4 hours when preeclampsia is present. Visitors should be limited to allow for rest and prevent overstimulation.
The nurse is preparing the client assignments for the day to a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Which clients should the nurse assign to the LPN because of client needs that cannot be met by UAP? Select all that apply.
- A. A client requiring frequent suctioning
- B. A client requiring a dressing change to the foot
- C. A client requiring range-of-motion exercises twice daily
- D. A client requiring reinforcement of teaching about a diabetic diet
- E. A client on bed rest requiring vital sign measurement every 4 hours
- F. A client requiring collection of a urine specimen for urinalysis testing
Correct Answer: A,B,D
Rationale: Delegation is the transferring to a competent individual the authority to perform a nursing task. When the nurse plans client assignments, he or she needs to consider the educational level and experience of the individual and the needs of the client. The LPN is trained to perform all the tasks indicated in the options; the clients who have needs that cannot be met by the UAP are those requiring suctioning, a dressing change, and reinforcement of teaching about a diabetic diet. UAP are trained to perform range-of-motion exercises, measure vital signs, and collect a urine specimen.
The nurse is planning care for a client with a diagnosis of acute glomerulonephritis. Which action should the nurse instruct the unlicensed assistive personnel (UAP) to implement in the care of the client?
- A. Ambulate the client frequently.
- B. Encourage a diet that is high in protein.
- C. Monitor the temperature every 2 hours.
- D. Remove the water pitcher from the bedside.
Correct Answer: D
Rationale: A client with acute glomerulonephritis commonly experiences fluid volume excess and fatigue. Interventions include fluid restriction, as well as monitoring weight and intake and output. The client may be placed on bed rest or at least encouraged to rest because a direct correlation exists among proteinuria, hematuria, edema, and increased activity levels. The diet is high in calories but low in protein. It is unnecessary to monitor the temperature as frequently as every 2 hours.
To ensure that the client self-administers medications safely in the home, which action plan should the nurse implement?
- A. Perform a pill count of each prescription bottle at every home visit.
- B. Instruct the client to double up on a medication when a dose is missed.
- C. Provide information on the purpose of all the prescribed medications.
- D. Ask the client to explain and demonstrate self-administration procedures.
Correct Answer: D
Rationale: To ensure safe administration of medication, the nurse asks the client to explain and demonstrate correct self-administration of medication procedures because demonstrating the proper procedure for the client does not ensure that the client can safely perform any procedure. Usually it is not acceptable to double up on missed medication and conducting a pill count on each visit is unrealistic and disrespectful.