Which is the least desirable outcome of using an external urinary catheter for a male client?
1. The client urinates at least every 4 hours.
2. The client's urine is dark yellow and clear.
3. The penis' skin under the catheter is dusky.
4. The client applies the catheter independently.
3
3. Dusky skin regardless of the location is cause for concern because it is a clinical indicator of tissue hypoxia. If the tissue is hypoxic, the perfusion is probably inade-quate to meet tissue oxygen demand and increases the risk of skin breakdown.
1. Urinating at least every 4 hours is a desirable outcome.
2. Clear urine is a desirable outcome because it indicates urine that is free of sediment and not infected. The dark yellow color can indicate dehydration.
4. Ability to perform self-care for a urinary catheter depends on the physical abilities and motivation of the client, but it is generally a desirable outcome.
You might also like to view...
A 14-year-old girl is anxious about not having reached menarche. When taking the health history, the nurse should ascertain which of the following? The age that:
a. The girl began to develop breasts. b. Her mother developed breasts. c. She began to develop pubic hair. d. She began to develop axillary hair.
The nurse is caring for a newborn who is being breastfed. What will the nurse expect the stool color to be 2 days after birth?
a. Yellow b. Brown c. Greenish brown d. Black and tarry
The obstetrician performed a vaginal examination on a client in her third trimester and gave a sudden push on the cervix. Later, the client asks the nurse what the procedure was and why it was done
The MOST appropriate response from the nurse would be: a. ballottement (fetal rebound) c. lightening (uterine reflex) b. Braxton Hicks (contractions) d. quickening (fetal movement)
Which statement(s) about total parenteral nutrition is (are) true? (Select all that apply.)
a. Assessing fluid volume status and preventing infection are important nursing considerations. b. Fingerstick glucose levels are assessed every 6 hours and prn. c. Total parenteral nutrition is administered through a feeding tube and pump. d. Total parenteral nutrition, with added lipids, provides adequate levels of protein, carbohydrates, and fats.