A charge nurse in a long-term care facility is observing another nurse who is inserting an indwelling urinary catheter into a female patient.
Which action by the nurse should prompt the charge nurse to intervene?
The nurse applies the sterile drape after cleaning the perineal area.
The nurse lubricates the indwelling urinary catheter.
The nurse separates the patient’s labia with her dominant hand.
The nurse provides perineal care prior to inserting the urinary catheter.
The Correct Answer is C
The correct answer is choice C.
Choice A rationale:
The nurse applies the sterile drape after cleaning the perineal area. This is correct because the perineal area should be cleaned before applying the sterile drape. Applying the drape first could potentially introduce bacteria to the catheter during insertion, increasing the risk of a urinary tract infection.
Choice B rationale:
The nurse lubricates the indwelling urinary catheter. This is a correct procedure as it helps to minimize discomfort and trauma during catheter insertion.
Choice C rationale:
The nurse separates the patient’s labia with her dominant hand. This is also a correct procedure. The nurse should use her non-dominant hand to separate the labia and expose the urethral meatus, and then use her dominant hand to insert the catheter.
Choice D rationale:
The nurse provides perineal care prior to inserting the urinary catheter. This is a correct procedure. Providing perineal care before inserting a urinary catheter is important to reduce the risk of introducing bacteria into the urinary tract. It’s part of maintaining strict aseptic technique during insertion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale:
Spinach is one of the most nutrient-dense vegetables. Just 1 cup (190 grams) of frozen spinach packs 12% of the DV for potassium. It’s also loaded with other nutrients. The same serving of frozen spinach contains 127% of the DV for vitamin A, 857% for vitamin K, 58% for folate, and 37% for magnesium.
Choice B rationale:
Potatoes are a staple food and are high in potassium. They are a versatile and filling food that can be included in a variety of dishes. Potatoes are also a good source of vitamin C and dietary fiber.
Choice C rationale:
Bananas are known as potassium-rich foods. A medium banana contains around 9% of the DV for this mineral. Most people consider it the go-to food to increase their potassium intake. However, bananas are not the only good source of potassium.
Choice D rationale:
Apples are a healthy choice and provide some potassium, but they are not as high in potassium as the other choices. Therefore, while apples are a good part of a balanced diet, they would not be the first recommendation for someone needing to increase their potassium intake.
Correct Answer is D
Explanation
Choice A rationale:
Dry skin is not typically associated with respiratory alkalosis. Respiratory alkalosis occurs when the levels of carbon dioxide and oxygen in the blood aren’t balanced, often due to hyperventilation. Dry skin is not listed as a common symptom of this condition.
Choice B rationale:
Diarrhea is not a common symptom of respiratory alkalosis. The condition is characterized by symptoms such as dizziness, numbness, confusion, and shortness of breath. Diarrhea is more commonly associated with gastrointestinal issues rather than respiratory conditions.
Choice C rationale:
Abdominal pain is not a typical symptom of respiratory alkalosis. The condition is usually caused by over-breathing
(hyperventilation) that occurs when you breathe very deeply or rapidly. Abdominal pain is not listed as a common symptom of this condition.
Choice D rationale:
Hyperventilation is typically the underlying cause of respiratory alkalosis. Hyperventilation, also known as overbreathing, occurs when someone breathes very deeply or rapidly. This can cause the levels of carbon dioxide in the blood to drop too low, leading to respiratory alkalosis. Therefore, a nurse assessing a client who has respiratory alkalosis should expect to find signs of hyperventilation.
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