A charge nurse is observing a newly-licensed nurse insert an Indwelling urinary catheter for a male client. Which of the following actions by the newly-licensed nurse requires intervention by the charge nurse?
Lubricates the first 2.5 to 5 cm (2 in) of the catheter.
Dons sterile gloves before cleaning the client's meatus.
Secures the tubing to the client's upper thigh.
Pulls gently on the catheter to check for resistance after inflating the balloon.
The Correct Answer is C
A. Lubricating the catheter helps reduce friction and discomfort during insertion.
B. Sterile gloves help prevent the introduction of microorganisms into the urinary tract.
C. Securing the tubing to the client's upper thigh can lead to discomfort and increased risk of skin irritation. The tubing should be secured to the client's lower abdomen or inner thigh to prevent tension and potential complications.
D. Gently pulling on the catheter after inflating the balloon helps ensure that the balloon is fully inflated and properly positioned in the bladder.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Urinary urgency refers to a sudden, compelling need to urinate, which may or may not be accompanied by frequency (i.e., the need to urinate often). Urgency alone does not necessarily indicate urinary incontinence but rather may suggest conditions like overactive bladder or urge incontinence. This finding is not the most characteristic sign of urinary incontinence but rather a symptom of specific types of incontinence or bladder conditions.
B. Loss of urine when laughing, coughing, or sneezing is indicative of stress urinary incontinence. This type of incontinence occurs when physical activities that increase abdominal pressure (such as coughing, sneezing, or laughing) lead to involuntary leakage of urine. It is a common and classic symptom of stress urinary incontinence.
C. Urinary hesitancy refers to difficulty starting the urine stream or a delay in beginning urination. This symptom is more commonly associated with obstructive urinary conditions or prostatic issues in males rather than incontinence. It does not typically characterize urinary incontinence, which is more related to involuntary leakage rather than difficulties initiating urination.
D. Hematuria is the presence of blood in the urine and can be a sign of various urological issues such as infections, stones, or tumors. It is not a typical finding associated with urinary incontinence, which involves involuntary leakage rather than the presence of blood.
Correct Answer is A
Explanation
A. Before administering an enteral feeding, it's important to discard any residual gastric contents to prevent aspiration. Aspirating and discarding the residual helps to assess gastric emptying and ensure that the stomach is able to tolerate the feeding.
B. While placing the client in a semi-Fowler's position is generally recommended during and after enteral feedings to help prevent aspiration, it's not necessary prior to administering the feeding.
C. Warming the feeding solution to body temperature can help to improve the client's comfort and may reduce nausea. However, it's not a critical step before administering the feeding.
D. Testing the pH of gastric aspirate is important to assess for gastric placement and to ensure that the tube is not in the lungs. However, it's typically done prior to the initial placement of the NG tube and is not routinely repeated before each feeding.
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