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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While milk is a good source of calcium, it is not beneficial for iron absorption. In fact, high calcium intake can inhibit iron absorption. Turkey is a good source of heme iron, which is more easily absorbed by the body compared to non-heme iron (found in plant-based sources). While turkey is beneficial, the combination with milk is not ideal due to the calcium interfering with iron absorption.
B. Like milk, yogurt is rich in calcium. Calcium can inhibit iron absorption, making yogurt less ideal for improving iron levels if consumed in large amounts with iron-rich foods. This is also a dairy product high in calcium. Combining it with yogurt does not enhance iron absorption and can hinder it.
C. Spinach is a good source of non-heme iron, though it contains oxalates, which can inhibit iron absorption. However, spinach can still contribute to overall iron intake. Beef is an excellent source of heme iron, which is easily absorbed by the body. Combining beef with spinach can help improve overall iron intake, despite the oxalates in spinach.
D. Fish, such as salmon or tuna, is a good source of heme iron, which is beneficial for increasing iron levels. Cottage cheese is a dairy product high in calcium, which can inhibit iron absorption if consumed in large amounts.
Correct Answer is A
Explanation
A. Checking the stockings for wrinkles is an important action. Wrinkles or folds in the stockings can create areas of increased pressure, which might lead to discomfort or skin breakdown and reduce the effectiveness of the stockings in preventing DVT. Ensuring that the stockings are smooth and free from wrinkles helps maintain proper compression and comfort.
B. Measuring the size of the client's foot is not typically required for properly fitting antiembolic stockings. The key measurements for antiembolic stockings are usually related to the calf, thigh, and sometimes the knee, not the foot.
C. Removing the stockings once each day is not usually recommended unless specifically instructed by a healthcare provider. Antiembolic stockings are generally worn continuously throughout the day and removed only for specific reasons, such as skin assessment or hygiene.
D. Applying the stockings while the client is sitting in a chair is not the preferred method. Antiembolic stockings should be applied while the client is lying down or in a supine position. This helps ensure that the stockings are applied evenly and that they provide consistent compression without causing undue pressure or discomfort.
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