114.

The nurse is teaching a 40-year-old man diagnosed with a lower motor

neuron disorder to perform intermittent self-catheterization at home. The
nurse should instruct the client to
1.
2.
3.
4.

use a new sterile catheter each time he performs a catheterization.

perform the Valsalva maneuver before doing the catheterization.
perform the catheterization procedure every 8 hours.
limit his fluid intake to reduce the number of times a catheterization is needed.

Strategy: Answers are implementations. Determine the outcome of each

answer choice. Is it desired?
(1) should use clean (not sterile) technique, used for clients with lower motor neuron
disorders
resulting in flaccid bladder
(2) correctclient holds breath and bears down as if trying to defecate, or uses Crede
maneuver
(places hands over bladder and pushes in and down), done to try to empty bladder
before catheterization
(3) usually done every 23 hours initially, and then increased to every 46 hours
(4) should encourage fluids
115. The nurse is preparing client assignments for the day. The nurse
should assign a LPN/LVN to which of the following clients?
1. A client
2. A client
feet.
3. A client
morphine.
4. A client

who had a total hip replacement and requires assistance with ambulation.
with type I diabetes mellitus who has bilateral 4+ pitting edema of the
with cholelithiasis scheduled for a cholecystectomy and receiving IV
6 hours postoperative after cystoscopy to remove a mass in the bladder.

Strategy: The LPN/LVN is assigned to stable patients with expected

outcomes.
(1) correctstable patient with expected outcome
(2) requires the assessment skills of the RN
(3) requires assessment and teaching
(4) requires assessment skills of RN
116. A client is admitted to the outpatient unit in the Cancer Center for
chemotherapy. The client is lethargic, weak, and pale. During
chemotherapy, which of the following nursing interventions would be MOST
important?
1.
2.
3.
4.

Establish emotional support.

Position for physical comfort.
Maintain droplet precautions.
Perform handwashing prior to care.