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 A

Explanation

A. “I will call for pain medication before the previous dose wears off.”

The statement "I will call for pain medication before the previous dose wears off" indicates an understanding of proactive pain management. In postoperative pain control, it is generally more effective to stay ahead of the pain by taking pain medication on a scheduled basis rather than waiting until the pain becomes severe. This approach helps to maintain a more consistent level of pain relief.

B. “I will call for pain medication as my pain becomes intolerable.”

Waiting until the pain becomes intolerable may result in suboptimal pain control. It's more effective to take pain medication before reaching a point of intolerable pain.

C. “I will wait for you to evaluate my pain before asking for more.”

Waiting for the nurse to evaluate pain before requesting more medication may result in delays in pain relief. Pain management often involves collaboration between healthcare providers and patients, and timely communication about pain levels is essential.

D. “I will ask for less medication to avoid addiction.”

This statement reflects a concern about addiction but may lead to inadequate pain relief. Pain management should prioritize effective pain control while balancing the risks and benefits of medications. The goal is to provide sufficient pain relief without compromising the client's well-being.

A. Set the pad’s temperature to 42.2° C (108 F) B. Stop the treatment if the client’s skin becomes red. C. Leave the pad in place for at least 40 min. D. Use safety pins to keep the pad in place.

Correct Answer is B

Explanation

A. Set the pad’s temperature to 42.2° C (108 F).

The specific temperature setting for a heat application should be based on the healthcare provider's prescription and the therapeutic goals. The temperature should be within a safe and therapeutic range.

B. Stop the treatment if the client’s skin becomes red.

This is the correct choice. Redness on the skin during heat application may indicate potential skin irritation or the onset of a burn. Stopping the treatment if redness occurs is crucial to prevent further injury.

C. Leave the pad in place for at least 40 min.

The duration of heat application should also be based on the healthcare provider's prescription and therapeutic goals. Leaving the pad in place for a specific duration is important, but the exact time would depend on the therapeutic plan.

D. Use safety pins to keep the pad in place.

Safety pins should not be used to secure heat applications, as they can pose a risk of injury. Instead, healthcare professionals should use the appropriate securing devices provided with the heat application or follow facility protocols.

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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?

Nursing Test Bank

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