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 A
Explanation
A. A urine output of 175 mL over 8 hours is significantly below normal, which is generally considered less than 0.5 mL/kg/hr in adults (the normal range is about 0.5-1.5 mL/kg/hr). Reduced urine output can be indicative of acute kidney injury or worsening renal function, and it needs prompt evaluation and intervention.
B. This finding is generally not urgent but could be noted. Strong-smelling urine, especially in the morning, may be due to concentration of waste products overnight or dietary factors. While it might suggest dehydration or infection, it is less immediately concerning than changes in urine output. If accompanied by other symptoms such as pain, fever, or changes in urine color, it might warrant further investigation.
C. This finding is typically within normal limits and may not need immediate reporting. Normal urine output is about 800-2,000 mL per day. An output of 2,200 mL is slightly elevated but still within the normal range, depending on fluid intake.
D. This finding is generally not urgent but worth noting. Cloudy urine can result from the presence of cells, bacteria, or other substances. It may become cloudy after standing due to the formation of crystals or precipitation of substances.
Correct Answer is A
Explanation
A. The recommendation to introduce whole milk is typically at 12 months of age. By this time, the infant's digestive system is mature enough to handle whole milk, and they have likely begun eating a variety of solid foods. Whole milk provides essential nutrients such as calcium and vitamin D, which are important for the child’s development at this stage.
B. At 10 months, the infant is still primarily reliant on breast milk or formula for their nutritional needs. Introducing whole milk before 12 months is generally not recommended because the infant's digestive system might not be fully developed to handle whole milk, and it may not provide adequate nutrition compared to breast milk or formula.
C. At 8 months, the infant is usually beginning to explore solid foods but is still dependent on breast milk or formula for the majority of their nutrition. Whole milk is not recommended at this age as the infant’s digestive system is not yet mature enough to handle it, and the nutritional needs are best met with breast milk or formula.
D. By 6 months, infants are typically starting to be introduced to solid foods but should continue receiving breast milk or formula as their primary source of nutrition. Whole milk is not recommended at this age as the infant’s kidneys and digestive system are not fully developed to process it.
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