The nurse has just removed an indwelling catheter from a patient following transurethral resection of the prostate. What action by the nurse is most important?
a. Monitor vital signs.
b. Watch for bladder spasms.
c. Offer the urinal every 15 minutes.
d. Collect serial samples of urine to monitor for color.
ANS: D
Serial urine samples may be collected after the Foley catheter has been removed. To do this, each time the patient urinates, save some of the urine in a transparent cup, and make sure to line up the cups in order (usually on a shelf in the bathroom). This way the nurse or physician can see whether the urine is becoming progressively less bloody and clearer with each void. Vital signs are always important but are not specific to removing a catheter. Bladder spasms are more likely early while the catheter is in place. Offering the urinal every 15 minutes is not necessary.
You might also like to view...
The perinatal nurse explains to the new nurse that the maternal pelvic shape can determine the fetal presentation. A fetus in a transverse presentation may be due to which maternal pelvic type:
A) Gynecoid B) Platypelloid C) Anthropoid D) Android
An infant in the newborn nursery has hyperbilirubinemia. Which assessment would the nurse recognize as pathologic hyperbilirubinemia?
a. Jaundice was present the first day of life. b. The infant was born at 37 weeks' gestation. c. The total serum bilirubin level was 6 mg/dL on the second day of life. d. The total serum bilirubin has decreased 6 mg/dL over the past 3 days.
Which key features does the nurse most likely find when performing a physical assessment on a patient with a small bowel obstruction?
a. Visible peristaltic waves in the upper and middle abdomen b. Minimal or no vomiting c. No major fluid and electrolyte imbalances d. Metabolic acidosis
The patient with cardiovascular disease must be taught how to reduce the risk of cardiovascular disease by balancing calorie intake with exercise to maintain a healthy body weight. In addition to this, the nurse instructs the patient to
a. Eat fish at least 5 times per week. b. Limit saturated fat to less than 7%. c. Limit cholesterol to less than 200 mg/day. d. Avoid high-fiber foods.