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.
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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Related Questions
Correct Answer is C
Explanation
A. Massage the client’s bony prominences:
Massaging bony prominences is generally not recommended for individuals at risk for pressure ulcers. Massage can increase friction and shear forces on the skin, which may contribute to skin damage rather than prevent it. Gentle, careful handling of the skin is preferable.
B. Keep the head of the bed elevated:
While elevating the head of the bed may be appropriate for certain medical conditions, it is not a primary preventive measure for pressure ulcers. In fact, keeping the head of the bed elevated continuously can contribute to pressure on the sacrum and coccyx, increasing the risk of pressure ulcers in those areas.
C. Reposition the client at least every 2 hr:
Regular repositioning is a crucial preventive measure for pressure ulcers. Repositioning helps redistribute pressure, improves blood flow to vulnerable areas, and reduces the risk of skin breakdown.
D. Keep the client’s skin moist:
While maintaining skin moisture is important to prevent dryness and cracking, excessive moisture can contribute to skin breakdown. The emphasis should be on keeping the skin clean and dry, with the use of moisturizers applied judiciously to prevent excessive dryness.
Correct Answer is C
Explanation
A. “Turn each of your hands and forearms so your palm is facing down.”
This describes pronation, not supination. In pronation, the palm faces down, and the radius crosses over the ulna.
B. “Take each of your hands and touch your shoulders.”
This describes flexion at the elbow joint, not supination. Flexion involves decreasing the angle between body parts.
C. “Turn each of your hands and forearms so your palm is facing up.”
This is the correct choice. Supination involves turning the hands and forearms so that the palms face up, and the radius and ulna are parallel.
D. “Move each of your arms to rest at your sides.”
This describes adduction, bringing the arms back to the sides of the body, not supination.
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