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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Metabolic alkalosis Metabolic alkalosis is a condition that occurs when your body has too many bases. It can occur due to prolonged vomiting, use of diuretics, or an overuse of antacids. In the context of Chronic Obstructive Pulmonary Disease (COPD), metabolic alkalosis is not typically a direct result of the disease. COPD primarily affects the respiratory system and does not directly cause an imbalance of bases in the body.

Choice B rationale:

Respiratory acidosis Respiratory acidosis is a condition that occurs when the lungs can’t remove enough carbon dioxide (CO2). This leads to a buildup of CO2 in the body, causing the pH of the blood to decrease and become more acidic. This is the most common acid-base imbalance seen in patients with COPD1. COPD can cause an alteration in respiratory exchanges, leading to retention of CO21. The consequence of hypercapnia due to alteration of gas exchange in COPD patients mainly consists in an increase of H+ concentration and development of respiratory acidosis.

Respiratory alkalosis Respiratory alkalosis is a condition that occurs when there is too little carbon dioxide in the body, often due to hyperventilation. In the context of COPD, this is less likely because COPD patients often have difficulty expelling carbon dioxide, not an excess of it being expelled.

Choice D rationale:

Metabolic Acidosis Metabolic acidosis occurs when the body produces too much acid, or when the kidneys are not removing enough acid from the body. This can occur due to conditions such as kidney disease, lactic acidosis, or ketoacidosis. While COPD can have wide-ranging effects on the body, it does not typically cause metabolic acidosis directly.

A. Wheezing. B. Decreased deep tendon reflexes. C. Hypoactive bowel sounds. D. Cerebral edema.

Correct Answer is B

Explanation

The correct answer is: B. Decreased deep tendon reflexes.

Choice A rationale: Wheezing is not typically associated with hyperkalemia. It is more commonly related to respiratory conditions.

Choice B rationale: Hyperkalemia can cause decreased deep tendon reflexes due to the effect of high potassium levels on nerve conduction and muscle function.

Choice C rationale: Hypoactive bowel sounds are not a common sign of hyperkalemia. They are more often associated with gastrointestinal issues.

Choice D rationale: Cerebral edema is not related to hyperkalemia. It is usually associated with conditions affecting the brain, such as trauma or infections.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has Chronic Obstructive Pulmonary Disease (COPD). Which of the following acidbase imbalances is the client at risk for?

Correct Answer is B

Explanation

A nurse is collecting data on a patient who has chronic kidney disease. Which finding is a sign of hyperkalemia?

Correct Answer is B

Explanation

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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?