When assuming care of a client at 1900, the nurse learns in report that a client with a urinary tract infection had an indwelling urinary catheter removed during the previous shift. Which information is most important for the nurse to obtain?
When the client voided following catheter removal.
Time of the last dose of IV antibiotic administration.
Intake and output reports for the previous shift.
Color of the urine during the catheter removal.
The Correct Answer is A
Choice A rationale
Knowing when the client voided following catheter removal is crucial because it indicates the return of the client’s ability to urinate after catheter removal. It helps assess urinary function and determines if the client is experiencing any urinary retention issues, which could potentially lead to complications such as urinary tract infections or bladder distention.
Choice B rationale
The time of the last dose of IV antibiotic administration is important for managing the client’s urinary tract infection, but it is not as immediately relevant as knowing when the client voided after catheter removal to assess urinary function.
Choice C rationale
Intake and output reports for the previous shift are important for assessing fluid balance and renal function, but knowing when the client voided after catheter removal takes precedence as it directly assesses urinary function and the need for further intervention.
Choice D rationale
The color of the urine during catheter removal may provide some insight into the client’s urinary condition, but it is not as critical as knowing when the client voided after catheter removal to assess urinary function.
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Correct Answer is ["B","E"]
Explanation
Choice A rationale
Drinking a mixture of warm water, whiskey, and honey at bedtime is not recommended as alcohol can disrupt sleep patterns and lead to poor sleep quality.
Choice B rationale
Establishing a regular time for going to bed and getting up helps regulate the body’s internal clock and can improve sleep quality.
Choice C rationale
Asking for a mild sedative should be a last resort and only used under the guidance of a healthcare provider. Non-pharmacological methods are preferred for improving sleep
.
Choice D rationale
Taking an afternoon nap can interfere with nighttime sleep and is generally not recommended for those having trouble sleeping at night.
Choice E rationale
Avoiding caffeinated beverages late in the day can help improve sleep quality as caffeine is a stimulant that can interfere with falling asleep.
Correct Answer is D
Explanation
Choice A rationale
Providing client-focused information is essential, but it does not confirm that the client has understood the critical information. It is a part of the teaching process but not a confirmation strategy.
Choice B rationale
Reinforcing key points with the client helps emphasize important information but does not ensure that the client has learned and understood it. It is a supportive strategy rather than a confirmation method.
Choice C rationale
Observing the client’s body language can provide clues about their understanding and comfort level but is not a definitive way to confirm learning. It should be used in conjunction with other strategies.
Choice D rationale
Asking the client for learning feedback is the most effective strategy for confirming that the client has understood the critical information. It encourages active participation and allows for real-time clarification.