Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include? (Select all that apply).
A. Measurement of residual urine after urination
Measurement of residual urine after urination is an indication of urinary catheterization because it can help diagnose conditions such as neurogenic bladder, bladder outlet obstruction, or urinary retention.
B. An open perineal wound
An open perineal wound is an indication for urinary catheterization because it can prevent contamination of the wound by urine and facilitate wound healing.
C. Relief of urinary retention
Relief of urinary retention is an indication of urinary catheterization because it can prevent complications such as bladder distension, infection, or renal damage.
D. Convenience for the nursing staff or the client's family
Convenience for the nursing staff or the client's family is not an indication of urinary catheterization because it can increase the risk of catheter-associated urinary tract infection (CAUTI), trauma, or encrustation.
E. routine acquisition of a urine specimen
routine acquisition of a urine specimen is not an indication for urinary catheterization because it can be obtained by other methods such as clean catch, midstream, or suprapubic aspiration.
This question is an excerpt from Nurse Dive's nursing test bank - RN Ati fundamental of nursing proctored exam. Take the full exam now
Full Explanation
A. Measurement of residual urine after urination is an indication of urinary catheterization because it can help diagnose conditions such as neurogenic bladder, bladder outlet obstruction, or urinary retention.
B. An open perineal wound is an indication for urinary catheterization because it can prevent contamination of the wound by urine and facilitate wound healing.
C. Relief of urinary retention is an indication of urinary catheterization because it can prevent complications such as bladder distension, infection, or renal damage.
D. Convenience for the nursing staff or the client's family is not an indication of urinary catheterization because it can increase the risk of catheter-associated urinary tract infection (CAUTI), trauma, or encrustation.
E. routine acquisition of a urine specimen is not an indication for urinary catheterization because it can be obtained by other methods such as clean catch, midstream, or suprapubic aspiration.
Similar Questions
A nurse is planning care for an older adult client who is at risk for developing pressure ulcers.
Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?
A. Elevate the head of the bed no more than 45°.
The head of the bed should generally be elevated no more than 30° to reduce shear and friction, not 45°.
B. Use a transfer device to lift the client up in bed.
Using a transfer device to lift the client prevents shearing and friction, which helps maintain skin integrity and reduces the risk of pressure ulcers.
C. Massage the skin over the client's bony prominences.
Massaging bony prominences is not recommended, as it can damage underlying tissue and increase risk of ulcer formation.
D. Apply cornstarch to keep sensitive skin areas dry.
Cornstarch is not advised because it can create a moist environment that promotes skin breakdown and infection.
Full Explanation
A. The head of the bed should generally be elevated no more than 30° to reduce shear and friction, not 45°.
B. Using a transfer device to lift the client prevents shearing and friction, which helps maintain skin integrity and reduces the risk of pressure ulcers.
C. Massaging bony prominences is not recommended, as it can damage underlying tissue and increase risk of ulcer formation.
D. Cornstarch is not advised because it can create a moist environment that promotes skin breakdown and infection.
A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client?
A. Lactated Ringer's
Lactated Ringer's is a balanced electrolyte solution, but it contains sodium in a similar concentration to normal serum levels. It is not appropriate for a client with hypernatremia, as it could further increase their sodium levels.
B. 0.45% sodium chloride
0.45% sodium chloride, also known as half-normal saline, is a hypotonic solution with a lower concentration of sodium than normal serum levels. It can help to lower the sodium levels in a client with hypernatremia by diluting the excess sodium in the body.
C. Dextrose 5% in 0.9% sodium chloride
Dextrose 5% in 0.9% sodium chloride is a hypertonic solution that contains both dextrose and sodium. It would not be appropriate for a client with hypernatremia, as it could exacerbate the condition.
D. Dextrose 10% in water
Dextrose 10% in water is a hypertonic solution with a high concentration of dextrose.It does not contain sodium, but it is still a hypertonic solution and not appropriate for a client with hypernatremia.
Full Explanation
A. Lactated Ringer's is a balanced electrolyte solution, but it contains sodium in a similar concentration to normal serum levels. It is not appropriate for a client with hypernatremia, as it could further increase their sodium levels.
B. 0.45% sodium chloride, also known as half-normal saline, is a hypotonic solution with a lower concentration of sodium than normal serum levels. It can help to lower the sodium levels in a client with hypernatremia by diluting the excess sodium in the body.
C. Dextrose 5% in 0.9% sodium chloride is a hypertonic solution that contains both dextrose and sodium. It would not be appropriate for a client with hypernatremia, as it could exacerbate the condition.
D. Dextrose 10% in water is a hypertonic solution with a high concentration of dextrose.
It does not contain sodium, but it is still a hypertonic solution and not appropriate for a client with hypernatremia.
A nurse administers an incorrect medication to a client. Following an assessment of the client, the nurse determines that the client has experienced no untoward effects as a result of the medication. The nurse does not complete an incident report because no harm came to the client.
Which of the following ethical principles did the nurse violate?
A. Beneficence
The nurse violated the ethical principle of Beneficence by not completing an incident report. Beneficence involves taking actions that promote the well-being and safety of the client. Failing to report an incorrect medication administration, even if no harm occurred, could potentially jeopardize the well-being of future clients.
B. Autonomy
Autonomy refers to the right of the client to make decisions about their own care and treatment. While it is an important ethical principle, it is not directly relevant to the nurse's failure to complete an incident report.
C. Veracity
Veracity involves truthfulness and honesty. While not completing an incident report may be seen as a lack of transparency, the primary ethical principle violated in this scenario is beneficence.
D. Confidentiality
Confidentiality pertains to protecting the privacy and confidentiality of client information. This principle is not directly related to the nurse's failure to complete an incident report.
Full Explanation
A. The nurse violated the ethical principle of Beneficence by not completing an incident report. Beneficence involves taking actions that promote the well-being and safety of the client. Failing to report an incorrect medication administration, even if no harm occurred, could potentially jeopardize the well-being of future clients.
B. Autonomy refers to the right of the client to make decisions about their own care and treatment. While it is an important ethical principle, it is not directly relevant to the nurse's failure to complete an incident report.
C. Veracity involves truthfulness and honesty. While not completing an incident report may be seen as a lack of transparency, the primary ethical principle violated in this scenario is beneficence.
D. Confidentiality pertains to protecting the privacy and confidentiality of client information. This principle is not directly related to the nurse's failure to complete an incident report.