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.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Stripping the client’s chest tube every 2 hours is not recommended. Stripping can create high negative pressures in the tube that can cause damage to the lung tissue. It can also lead to increased pain for the patient and is generally not a standard practice in chest tube management.
Choice B rationale:
Looping the tubing of the chest tube on the client’s bed is not a recommended practice. The chest tube should be free of loops or kinks to allow for proper drainage of air and fluid from the pleural space. Any loops or kinks in the tube can lead to accumulation of fluid or air, which can cause complications such as tension pneumothorax.
The chest tube drainage system should not be placed above the level of the client’s heart. This can lead to the backflow of blood or fluid into the pleural space, which can cause complications such as hemothorax or pleural effusion. The drainage system should always be kept below the level of the client’s chest to allow for gravity-assisted drainage.
Choice D rationale:
Taping the connections on the client’s chest tube is a recommended practice. This is done to secure the connections and prevent accidental disconnection or dislodgement of the tube. An accidental disconnection or dislodgement can lead to complications such as pneumothorax or hemothorax. Therefore, all connections should be securely taped to prevent any accidental disconnections.
Correct Answer is D
Explanation
Choice A rationale:
Prone The prone position, in which a patient lies facedown, is beneficial for patients with pneumonia as it helps shift the fluid away from the back of the lungs, allowing more air to enter. It also improves ventilation in the lungs and reduces the risk of lung collapse. However, this position is not the most effective for maximum lung expansion in pneumonia patients.
Choice B rationale:
Side-lying Lateral positioning, in which the patient lies on one side, is recommended for patients suffering from pneumonia in just one lung. In this position, the pneumatic lung is exposed to a higher blood flow, resulting in greater oxygenation levels and improved lung expansion. This position can also help prevent lung injury by helping regulate pressure and improve aeration.
But again, this is not the most effective position for maximum lung expansion in pneumonia patients.
Choice C rationale:
Supine The supine position, where the patient lies flat on their back, is not the best position for a pneumonia patient. This position can cause the secretions to pool in the lungs, making it harder for the patient to breathe and potentially worsening their condition. Choice D rationale:
Upright Elevating the head of the bed is an effective way to improve lung expansion and oxygenation levels in pneumonia patients. This position also helps eliminate airway obstruction, reduces pressure on the lungs, and promotes drainage of fluids from the lungs. Therefore, the upright position is the most recommended for maximum lung expansion in pneumonia patients.
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