1. A 55-year-old male client has a 16-Fr indwelling urethral catheter with a 5-mL balloon inserted
to relieve postoperative urinary retention. The nurse observes urine leaking from the insertion
site, past the catheter. What is the nurse's first action?
1. Check the urethral catheter and
drainage tubing
2. Irrigate the catheter with 30 mL sterile
normal saline
3. Notify the health care provider
4. Remove and reinsert the next larger size
catheter
Obstruction (eg, clots, mucus, thick sediment) and kinking/compression of a catheter or tubing,
bladder spasms, and improper catheter or balloon size can cause leakage of urine from the insertion
site of an indwelling urinary catheter (Foley).
The nurse's first action should be to assess for a mechanical obstruction by inspecting the urethral
catheter and drainage tubing. The nurse should try to alleviate the causes of the obstruction of urine
from the bladder by performing the following as necessary:
Remove kinking or compression of the catheter or tubing
Attempt to dislodge a visible obstruction by milking the drainage tubing. This involves
squeezing and releasing the full length of the tubing, starting from a point close to the client
and ending at the drainage bag (Option 1).
If the above interventions fail, the nurse should notify the health care provider (HCP) (Option 3).
(Option 2) Irrigation is usually avoided because pus or sediments that may be present can be
washed back into the bladder; however, it is sometimes prescribed to relieve an obstruction to the
flow of urine. If there is a discrepancy in expected urine output compared to fluid intake, a blockage
of the urine flow is suspected and a bladder scan can be performed first to confirm the presence of
urine in the bladder. Furthermore, the nurse would not irrigate the catheter without a prescription
from the HCP, and so this is not the first action.
(Option 4) The client has the recommended size catheter and balloon for an adult male. The HCP
must provide a prescription for removal and reinsertion of a different-size catheter, so this is not the
first action.
Educational objective:
If leakage of urine is observed from the insertion site of an indwelling urinary catheter, the nurse
should assess for common causes that can impede the flow of urine. These include obstruction (eg,
clots, mucus, thick sediment), kinking, or compression of the catheter or drainage tubing; bladder
spasms; and improper catheter size.
2. A client with a tracheostomy is alert and oriented and able to tolerate oral intake. Which
action would be appropriate to reduce the client's risk of aspiration pneumonia?
, 1. Fully inflate the cuff before feeding
2. Have the client sit in an upright position with the neck hyperextended
3. Partially or fully deflate the cuff
4. Provide a modified diet of pureed foods
A tracheostomy tube with inflated cuff is used in clients who are at risk for aspiration (eg, who are
unconscious or on mechanical ventilation). However, an inflated cuff is uncomfortable for clients who
are awake because it is difficult to swallow or talk. The cuff is deflated when the client is improving, is
determined not to be at risk of aspiration, and is awake. Before the cuff is deflated, the client is asked
to cough (if possible) to expectorate the oropharyngeal secretions that have built up above the
inflated cuff. In addition, suction is applied through the tracheostomy tube and then the mouth; the
cuff is then deflated.
Additional interventions to
decrease the risk of aspiration
include the following:
Having the client sit
upright with the chin
flexed slightly toward the
chest
Monitoring for a wet or
garbled-sounding voice
Monitoring for signs of
fever
(Option 1) Inflating the cuff
makes it difficult for a client who is
awake to swallow and talk. In
addition, more secretions can accumulate above the inflated cuff due to difficulty swallowing. The
inflated cuff may not provide a 100% seal and the accumulated secretions can slide through it,
causing aspiration. For these reasons, the deflated cuff is beneficial in awake clients with no risk of
aspiration.
(Option 2) Having the client sit upright will help reduce the risk of aspiration. However, the chin
should be flexed toward the chest; hyperextension of the neck increases the risk of aspiration.
(Option 4) There is no reason to give pureed foods just because the client has a tracheostomy. The
client's diet should be determined by a swallowing evaluation.
Educational objective:
The risk of aspiration in a conscious, alert, and oriented client with a tracheostomy can be reduced by
partially or fully deflating the tracheostomy cuff, having the client in an upright position, monitoring for
a wet cough or voice quality, and monitoring vital signs.
, 3. The nurse reinforces the physical therapist's teaching regarding the use of a cane when
caring for a client with osteoarthritis of the left knee. Which client statement indicates
the need for further teaching?
1. "I will hold the cane in my right hand."
2. "I will move my left leg forward after moving the cane."
3. "I will place the cane several inches in front of and to the
side of my right foot."
4. "My cane should equal the distance from my waist to the
floor."
Explanation:
Clients with one-sided weakness or injury, increased joint pressure, or poor balance can use a cane
to provide support and stability when walking. Cane length should equal the distance from the
client's greater trochanter to the floor as incorrect cane length can cause back injury. A cane
measured from the waist would be too long to provide optimal support (Option 4).
Teaching points to assist a client in appropriate use of a cane include:
1. Hold the cane on the stronger side to provide maximum support and body alignment,
keeping the elbow slightly flexed (20-30 degrees) (Option 1).
2. Place the cane 6"-10" (15-25 cm) in front of and to the side of the foot to keep the body
weight on both legs to provide balance (Option 3).
3. For maximum stability,
move the weaker leg
forward to the level of
the cane, so that body
weight is divided
between the cane and
the stronger leg (Option
2). If minimal support is
needed, the cane and
weaker leg are
advanced forward at the
same time.
4. Move the stronger leg
forward past the cane
and the weaker leg, so
the weight is divided
between the cane and
the weaker leg.
5. Always keep at least 2 points of support on the floor at all times.
, Educational objective:
Clients should hold the cane on the stronger side to provide maximum stability. Cane length should
equal the distance from the greater trochanter to the floor.
4. A client with advanced Alzheimer's dementia is admitted to a skilled nursing facility for
delirium. The nurse determines that the client can bear weight partially. Which would
be the most appropriate method for the nurse to use to transfer this client safely?
1. 1-person stand and pivot with a gait
belt and walker
2. 2-person full-body sling lift
3. 2-person motorized standing-assist lift
4. 2-person stand and pivot with a gait
belt and walker
To determine the most appropriate method to transfer a client safely for the first time, the nurse
should assess:
1. Whether the client can bear weight
2. Whether the client is cooperative
Given this client's recent delirium and history of advanced Alzheimer's dementia, full participation and
cooperation with instructions during the transfer is unlikely. As a result, a pivot transfer would be
unsafe. A standing-assist lift may also be unsafe as this also requires that the client follow directions
during the transfer. Therefore, a full-body sling lift should be used to transfer this client safely,
particularly during the early phase of hospitalization (Option 2).
(Options 1 and 4) A pivot transfer requires client cooperation with instructions during the transfer.
(Option 3) A standing-assist lift transfer also requires client cooperation with instructions to promote
safety during the transfer.
Educational objective:
A client who can bear weight partially but is unable to cooperate with instructions will require a full-
body sling lift and 2 caregivers for safe transfer.
5. The nurse is administering cleansing enemas to a client the night before bowel surgery.
During instillation of the enema, the client reports cramping and pain. What action should the
nurse take?
1. Have the client take slow, deep breaths
2. Stop infusing the solution for 30 seconds, then resume at a slower
rate
3. Tell the client that the process will not take much longer
4. Withdraw the tube approximately 2 cm and continue the infusion
Explanation:
to relieve postoperative urinary retention. The nurse observes urine leaking from the insertion
site, past the catheter. What is the nurse's first action?
1. Check the urethral catheter and
drainage tubing
2. Irrigate the catheter with 30 mL sterile
normal saline
3. Notify the health care provider
4. Remove and reinsert the next larger size
catheter
Obstruction (eg, clots, mucus, thick sediment) and kinking/compression of a catheter or tubing,
bladder spasms, and improper catheter or balloon size can cause leakage of urine from the insertion
site of an indwelling urinary catheter (Foley).
The nurse's first action should be to assess for a mechanical obstruction by inspecting the urethral
catheter and drainage tubing. The nurse should try to alleviate the causes of the obstruction of urine
from the bladder by performing the following as necessary:
Remove kinking or compression of the catheter or tubing
Attempt to dislodge a visible obstruction by milking the drainage tubing. This involves
squeezing and releasing the full length of the tubing, starting from a point close to the client
and ending at the drainage bag (Option 1).
If the above interventions fail, the nurse should notify the health care provider (HCP) (Option 3).
(Option 2) Irrigation is usually avoided because pus or sediments that may be present can be
washed back into the bladder; however, it is sometimes prescribed to relieve an obstruction to the
flow of urine. If there is a discrepancy in expected urine output compared to fluid intake, a blockage
of the urine flow is suspected and a bladder scan can be performed first to confirm the presence of
urine in the bladder. Furthermore, the nurse would not irrigate the catheter without a prescription
from the HCP, and so this is not the first action.
(Option 4) The client has the recommended size catheter and balloon for an adult male. The HCP
must provide a prescription for removal and reinsertion of a different-size catheter, so this is not the
first action.
Educational objective:
If leakage of urine is observed from the insertion site of an indwelling urinary catheter, the nurse
should assess for common causes that can impede the flow of urine. These include obstruction (eg,
clots, mucus, thick sediment), kinking, or compression of the catheter or drainage tubing; bladder
spasms; and improper catheter size.
2. A client with a tracheostomy is alert and oriented and able to tolerate oral intake. Which
action would be appropriate to reduce the client's risk of aspiration pneumonia?
, 1. Fully inflate the cuff before feeding
2. Have the client sit in an upright position with the neck hyperextended
3. Partially or fully deflate the cuff
4. Provide a modified diet of pureed foods
A tracheostomy tube with inflated cuff is used in clients who are at risk for aspiration (eg, who are
unconscious or on mechanical ventilation). However, an inflated cuff is uncomfortable for clients who
are awake because it is difficult to swallow or talk. The cuff is deflated when the client is improving, is
determined not to be at risk of aspiration, and is awake. Before the cuff is deflated, the client is asked
to cough (if possible) to expectorate the oropharyngeal secretions that have built up above the
inflated cuff. In addition, suction is applied through the tracheostomy tube and then the mouth; the
cuff is then deflated.
Additional interventions to
decrease the risk of aspiration
include the following:
Having the client sit
upright with the chin
flexed slightly toward the
chest
Monitoring for a wet or
garbled-sounding voice
Monitoring for signs of
fever
(Option 1) Inflating the cuff
makes it difficult for a client who is
awake to swallow and talk. In
addition, more secretions can accumulate above the inflated cuff due to difficulty swallowing. The
inflated cuff may not provide a 100% seal and the accumulated secretions can slide through it,
causing aspiration. For these reasons, the deflated cuff is beneficial in awake clients with no risk of
aspiration.
(Option 2) Having the client sit upright will help reduce the risk of aspiration. However, the chin
should be flexed toward the chest; hyperextension of the neck increases the risk of aspiration.
(Option 4) There is no reason to give pureed foods just because the client has a tracheostomy. The
client's diet should be determined by a swallowing evaluation.
Educational objective:
The risk of aspiration in a conscious, alert, and oriented client with a tracheostomy can be reduced by
partially or fully deflating the tracheostomy cuff, having the client in an upright position, monitoring for
a wet cough or voice quality, and monitoring vital signs.
, 3. The nurse reinforces the physical therapist's teaching regarding the use of a cane when
caring for a client with osteoarthritis of the left knee. Which client statement indicates
the need for further teaching?
1. "I will hold the cane in my right hand."
2. "I will move my left leg forward after moving the cane."
3. "I will place the cane several inches in front of and to the
side of my right foot."
4. "My cane should equal the distance from my waist to the
floor."
Explanation:
Clients with one-sided weakness or injury, increased joint pressure, or poor balance can use a cane
to provide support and stability when walking. Cane length should equal the distance from the
client's greater trochanter to the floor as incorrect cane length can cause back injury. A cane
measured from the waist would be too long to provide optimal support (Option 4).
Teaching points to assist a client in appropriate use of a cane include:
1. Hold the cane on the stronger side to provide maximum support and body alignment,
keeping the elbow slightly flexed (20-30 degrees) (Option 1).
2. Place the cane 6"-10" (15-25 cm) in front of and to the side of the foot to keep the body
weight on both legs to provide balance (Option 3).
3. For maximum stability,
move the weaker leg
forward to the level of
the cane, so that body
weight is divided
between the cane and
the stronger leg (Option
2). If minimal support is
needed, the cane and
weaker leg are
advanced forward at the
same time.
4. Move the stronger leg
forward past the cane
and the weaker leg, so
the weight is divided
between the cane and
the weaker leg.
5. Always keep at least 2 points of support on the floor at all times.
, Educational objective:
Clients should hold the cane on the stronger side to provide maximum stability. Cane length should
equal the distance from the greater trochanter to the floor.
4. A client with advanced Alzheimer's dementia is admitted to a skilled nursing facility for
delirium. The nurse determines that the client can bear weight partially. Which would
be the most appropriate method for the nurse to use to transfer this client safely?
1. 1-person stand and pivot with a gait
belt and walker
2. 2-person full-body sling lift
3. 2-person motorized standing-assist lift
4. 2-person stand and pivot with a gait
belt and walker
To determine the most appropriate method to transfer a client safely for the first time, the nurse
should assess:
1. Whether the client can bear weight
2. Whether the client is cooperative
Given this client's recent delirium and history of advanced Alzheimer's dementia, full participation and
cooperation with instructions during the transfer is unlikely. As a result, a pivot transfer would be
unsafe. A standing-assist lift may also be unsafe as this also requires that the client follow directions
during the transfer. Therefore, a full-body sling lift should be used to transfer this client safely,
particularly during the early phase of hospitalization (Option 2).
(Options 1 and 4) A pivot transfer requires client cooperation with instructions during the transfer.
(Option 3) A standing-assist lift transfer also requires client cooperation with instructions to promote
safety during the transfer.
Educational objective:
A client who can bear weight partially but is unable to cooperate with instructions will require a full-
body sling lift and 2 caregivers for safe transfer.
5. The nurse is administering cleansing enemas to a client the night before bowel surgery.
During instillation of the enema, the client reports cramping and pain. What action should the
nurse take?
1. Have the client take slow, deep breaths
2. Stop infusing the solution for 30 seconds, then resume at a slower
rate
3. Tell the client that the process will not take much longer
4. Withdraw the tube approximately 2 cm and continue the infusion
Explanation:
