A nurse notifies the provider immediately if a patient with an indwelling catheter
a. Complains of discomfort upon insertion of the catheter.
b. Places the drainage bag higher than the waist while ambulating.
c. Has not collected any urine in the drainage bag for 2 hours.
d. Is incontinent of stool and contaminates the external portion of the catheter.
ANS: C
If the patient has not produced urine in 2 hours, the physician needs to be notified immediately because this could indicate renal failure. Discomfort upon catheter insertion is unpleasant but unavoidable. The nurse is responsible for maintaining the integrity of the catheter by ensuring that the drainage bag is below the patient's bladder. Stool left on the catheter can cause infection and should be removed as soon as it is noticed. The nurse should ensure that frequent perineal care is being provided.
You might also like to view...
Which of the following statements best reflects the nurse's understanding of the primary nursing related purpose of a concept map?
1. To facilitate holistic nursing care 2. To provide visualization of the client's health problems 3. Assist in the identification of client-oriented nursing diagnoses 4. Demonstrate the relationship between the client's various health problems
Signs and symptoms that a woman should report immediately to her health care provider include (choose all that apply):
a. Vaginal bleeding. b. Rupture of membranes. c. Heartburn accompanied by severe headache. d. Decreased libido. e. Urinary frequency.
The nurse is preparing to assess a patient with Cushing syndrome. Which findings should the nurse expect to assess in this patient?
Select all that apply. 1. weight gain 2. auscultatory lung crackles 3. jugular vein distention 4. peripheral edema 5. hypotension
What is one performance area where quality improvement is used to effect process and outcomes of health care?
a. Provision of appropriate and effective care b. Elimination of access barriers c. Reduction of unjustified geographic variation in care d. Application of managed care to all citizens