A nurse is caring for a female client who has a prescription for an indwelling urinary catheter. Which of the following actions should the nurse take first?

Clean the perineum from front to back.

Lubricate the catheter.

Explain to the client that she will feel temporary discomfort.

Arrange the sterile items on the sterile field.

Answer and Explanation

The Correct Answer is D

A. Clean the perineum from front to back.

After arranging the sterile items, the next step involves preparing the client for catheter insertion, which includes cleaning the perineum from front to back using appropriate techniques to minimize the risk of infection.

B. Lubricate the catheter.

Following the preparation of the client, the next step involves lubricating the catheter before insertion. Lubrication facilitates the smooth and atraumatic insertion of the catheter.

C. Explain to the client that she will feel temporary discomfort.

Providing information and preparing the client for the procedure is an important aspect, but it typically follows the physical preparation steps. Explaining to the client about potential discomfort should be done before the procedure but after the necessary physical preparations are complete.

D. Arrange the sterile items on the sterile field.

This is the first action to be taken. It involves preparing all the necessary sterile items on a sterile field, ensuring that everything needed for the catheter insertion procedure is organized and ready to maintain aseptic technique.

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Correct Answer is B

Explanation

A. Kidney beans

Kidney beans are a good plant-based source of protein. They contain essential amino acids, but plant-based proteins may lack some amino acids found in animal-based sources. While kidney beans contribute to protein intake, they are not considered the best source of protein for wound healing among the given options.

B. Grilled salmon

Grilled salmon is indicated as the best source of protein for wound healing among the options. Salmon is an animal-based source that provides high-quality protein with all essential amino acids. It is also rich in omega-3 fatty acids, which have anti-inflammatory properties and can further support the healing process.

C. Peanut butter

Peanut butter is a source of protein, but it is also high in fats. While it can contribute to protein intake, it may not be as lean a source as grilled salmon. It's important to consider the overall nutritional profile when recommending it for wound healing.

D. Raw spinach

Spinach is a source of protein, but it is considered a plant-based protein. While it can contribute to overall protein intake, plant-based proteins may not provide as much protein per serving as animal-based sources like salmon. It also contains other nutrients, such as iron and vitamins, which are beneficial but not specifically highlighted for wound healing in this context.

A. “I will keep my baby’s head slightly elevated during the feeding.” B. “I will hold my baby close to me while feeding.” C. “Each feeding should last about 15 minutes.” D. “Propping a bottle can cause otitis media.”

Correct Answer is C

Explanation

A. “I will keep my baby’s head slightly elevated during the feeding.”

This statement is correct. Keeping the baby's head slightly elevated during feeding can help prevent ear infections (otitis media) and is a recommended practice.

B. “I will hold my baby close to me while feeding.”

Holding the baby close during feeding promotes bonding and is generally considered a good practice for both bottle-feeding and breastfeeding.

C. “Each feeding should last about 15 minutes.”

This statement indicates a need for further teaching. The duration of a feeding can vary among infants, and it's not advisable to put a strict time limit on each feeding. It's important to follow the baby's cues and allow for individual variations in feeding patterns.

D. “Propping a bottle can cause otitis media.”

This statement is correct. Propping a bottle can lead to ear infections (otitis media) and is not a safe or recommended practice. The baby should be held during feedings to prevent these issues.

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A nurse is caring for a female client who has a prescription for an indwelling urinary catheter. Which of the following actions should the nurse take first?

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