A nurse is assessing a patient who has mitral valve stenosis.
What symptoms should the nurse expect?

B. Confirm the patient’s identity by checking their wristband.
Explanation: Always begin by confirming the patient’s identity to ensure the correct treatment is given to the right patient. This step is critical in maintaining patient safety and is a standard part of care.

C. Provide privacy for the patient by closing the curtains.
Explanation: After confirming identity, ensuring privacy is important for the patient’s comfort and dignity. This is especially relevant for procedures like enemas, which may cause embarrassment or discomfort.

A. Assisting the patient into the Sims’ position.
Explanation: The Sims' position, where the patient lies on their left side with the right knee flexed, is the preferred position for enema administration. This position allows for easy insertion of the enema tube and ensures that gravity helps the solution flow into the rectum and colon.

D. Insert the tip of the enema tubing into the patient’s rectum.
Explanation: Once the patient is in the correct position, the nurse carefully inserts the enema tubing into the rectum, following proper technique to ensure patient safety and comfort.

The correct answer is Choice A: Don sterile gloves before inserting the indwelling urinary catheter.

Choice A rationale:

Donning sterile gloves is crucial to prevent infection during the insertion of an indwelling urinary catheter. Maintaining aseptic technique is essential to avoid introducing pathogens into the urinary tract.

Choice B rationale:

Applying an oil-based lubricant to the catheter is not recommended as it can interfere with the sterility of the procedure and potentially cause irritation or infection.

Choice C rationale:

Testing the balloon before insertion is important, but it is not the first step in the process. The priority is to ensure that the nurse is using sterile gloves to maintain aseptic technique.

Choice D rationale:

Using one cotton swab to clean the patient’s urinary meatus is not sufficient for proper aseptic technique. The area should be cleaned thoroughly with appropriate antiseptic solutions and sterile supplies.