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 D

Explanation

A. Yogurt:

Yogurt is not a significant source of iron. While yogurt provides various nutritional benefits, it is not considered an iron-rich food.

B. Oranges:

Oranges are a good source of vitamin C, which enhances the absorption of non-heme iron from plant-based foods. However, oranges themselves do not contain substantial amounts of iron. The combination of vitamin C-rich foods with iron-rich foods can be beneficial for iron absorption.

C. Turnips:

Turnips are a vegetable that, while nutritious, is not particularly high in iron. Additionally, the iron in plant-based foods like turnips is non-heme iron, which is less easily absorbed by the body compared to heme iron found in animal products.

D. Roast beef:

Roast beef is a good source of heme iron, which is more easily absorbed by the body. Red meat, such as roast beef, is a valuable dietary source of iron, especially for individuals with iron deficiency.

A. Remind the client to tell the nurse when he has to urinate B. Use adult diapers to prevent frequent clothing changes. C. Take the client to the bathroom on an every-2-hr schedule. D. Request a prescription for an indwelling urinary catheter.

Correct Answer is C

Explanation

A. Remind the client to tell the nurse when he has to urinate.
Reminding the client may not be effective, as individuals with dementia may have difficulty expressing their needs or may forget to communicate when they need to use the bathroom. It relies on the client's ability to remember and communicate.

B. Use adult diapers to prevent frequent clothing changes.
While adult diapers can be part of a comprehensive plan for managing incontinence, they should not be the sole intervention. Relying solely on diapers does not address the underlying causes of incontinence and may not promote optimal dignity and quality of life.

C. Take the client to the bathroom on an every-2-hr schedule.
This is the correct choice. Taking the client to the bathroom on a regular schedule (timed voiding) is a proactive approach to managing urinary incontinence in individuals with dementia. It helps reduce the likelihood of accidents by ensuring regular opportunities for toileting.

D. Request a prescription for an indwelling urinary catheter.
Indwelling urinary catheters are generally not recommended for managing routine urinary incontinence due to the associated risks, including infection. Catheters should be used judiciously and based on medical necessity.

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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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