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. Close the curtains around the client’s bed.

Closing the curtains around the client's bed is a practical way to maintain the client's privacy during a bed bath. This action provides a visual barrier, ensuring that the client is shielded from the view of others in the room.

B. Close the door of the client’s room.

Closing the door is another way to enhance privacy, but it may not be as feasible in all situations. Closing the curtains provides immediate visual privacy without necessarily closing off the entire room.

C. Ask family members to leave the room.

This option is appropriate if family members are present and their presence is not essential for the bed bath. Asking them to step out temporarily can enhance the client's privacy.

D. Use a blanket to cover the client.

While using a blanket is a way to cover and provide modesty during the bed bath, closing the curtains is a more direct measure to maintain visual privacy. Blankets can be used as needed during the bed bath process.

A. Instruct the client to tilt her head back when she swallows. B. Place food on the left side of the client’s mouth. C. Add thickener to fluids. D. Serve food at room temperature.

Correct Answer is C

Explanation

A. Instruct the client to tilt her head back when she swallows.

Tipping the head back during swallowing is not recommended, especially for individuals with dysphagia. It can increase the risk of aspiration, as it may interfere with the normal swallowing mechanism. The head should be kept in a neutral position during swallowing.

B. Place food on the left side of the client’s mouth.

Placing food on the side with weakness may lead to difficulty in chewing and increased risk of aspiration. The placement of food should be based on the individual's ability and preference, and it's important to consider the safety of swallowing.

C. Add thickener to fluids.

This is the correct choice. Adding thickener to fluids can help modify their consistency, making them easier to swallow and reducing the risk of aspiration. The appropriate thickness should be determined based on the individual's ability to swallow safely.

D. Serve food at room temperature.

While serving food at room temperature may be a preference for some individuals, it is not specifically addressing the safety concerns related to dysphagia and left-sided weakness. The focus should be on modifying food textures and consistencies to ensure safe swallowing.

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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

Naxlex Comprehensive Predictor Exams

A nurse is about to give a client a complete bed bath. Which of the following actions should the nurse take to maintain the client’s privacy?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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