A week later, at the interdisciplinary care conference, you report that bladder training is progressing and
recommend removing the catheter if N.H.'s mobility and communication abilities have progressed sufficiently.
The group and N.H. agree that she is ready for the Foley catheter to be removed.
Identify three problems that N.H. is at risk for developing after catheter removal, and
describe specific interventions for each problem.
Incontinence: Place the call light in reach, and respond rapidly to her request. Establish a regular
(q2h) voiding schedule with use of verbal cueing; offer the bedpan or transfer to the commode
every 2 hours, and clean genital area after each voiding. Provide fluids according to schedule, and
limit fluid intake 2 to 3 hours before bedtime. Monitor I&O carefully. Encourage N.H. to perform
Kegel exercises for 5 to 10 minutes four times a day, especially if stress urinary incontinence is
suspected. Place incontinent pads as appropriate. Provide N.H. with positive feedback when
episodes of incontinence decrease.
Difficulty with ambulation: Schedule ambulation after voiding to reduce the need to hurry. Dress
N.H. in nonrestrictive clothing and footwear that facilitates walking. Help her sit on the side of
the bed to facilitate postural adjustments. The physical therapist will use a gait belt to help with
ambulation and provide assistive devices for ambulation until N.H. is steady on her feet. The
physical therapist will chart distance ambulated, assistive devices used, and the number of staff
required. Help the patient establish realistic increments in distance for ambulation. Encourage her
to sit up in the chair as much as tolerated.
Urinary retention: Monitor I&O carefully. Monitor for bladder distention and discomfort. Help to
bedside commode (BSC) at regular intervals. Flush toilet, run water, or place N.H.'s hands in warm
water while she is on the BSC. Monitor post-void residual urine with a bedside bladder scan daily
as needed to make certain she is emptying her bladder. This procedure is quick, noninvasive, and
painless.
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The nurse administers a medication to the patient and then realizes that the medication had been discontinued. The error is immediately reported to the physician. The nurse is complying with the standards of professional performance known as:
a. Ethics. b. Socialization. c. Altruism. d. Autonomy.
How should you respond to the above patient?
A. Encourage her to finish her exercise session. B. Interrupt her and have her weighed immediately. C. Tell her she is not allowed to exercise. D. Interrupt her and encourage her to take a walk with you.
The nurse is preparing a client for ambulatory surgery. Which of the following is a recommended nursing function?
A) Administer regularly scheduled medications the morning of the procedure. B) Explain the procedure to the client and have him or her sign the consent form. C) Make sure the medication has worn off sufficiently for the client to drive home. D) Make sure the client has someone to stay with him or her for at least 8 hours after surgery.
L.W. says she is uncertain as to what to do and wants to know how long she has to decide
How will you respond? What will be an ideal response?