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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Noodles:
Noodles by themselves are typically a carbohydrate source and are lower in fat. However, it's essential to consider how they are prepared. If they are served with a high-fat sauce or other fatty ingredients, they may contribute to a higher fat intake.
B. Vegetable soup:
Vegetable soup, particularly if it is broth-based and contains a variety of vegetables, can be a healthy and lower-fat option. It provides vitamins, minerals, and fiber without a significant amount of fat.
C. Baked fish:
Baked fish is a lean source of protein and is generally lower in fat compared to fried or heavily processed options. The key is in the preparation method; baking is a healthier option than frying. However, it's essential to avoid high-fat toppings or sauces.
D. Cheddar cheese:
Cheddar cheese is a high-fat dairy product. Individuals with a history of pancreatitis are often advised to limit their fat intake, and high-fat foods like cheddar cheese can exacerbate symptoms. It's recommended to choose lower-fat or fat-free dairy alternatives.
Correct Answer is B
Explanation
A. Ensure the rope knots are away from the pulleys.
While ensuring that rope knots are away from the pulleys is a general principle in traction care to maintain proper functioning, it is not directly related to the specific positioning of the child's feet in Buck's traction.
B. Ensure the child’s feet are against the footboard.
This statement is correct. Ensuring that the child's feet are against the footboard helps maintain proper hip alignment and prevent complications such as contractures. It is an important aspect of care when managing Legg-Calve-Perthes disease in Buck's traction.
C. Apply antibiotic ointment to the pin sites daily.
This action is not applicable to Buck's traction. Buck's traction involves the use of a boot or splint, and it does not include pins or pin sites. The use of antibiotic ointment for pin sites is more relevant in the context of skeletal traction.
D. Reduce the child’s fluid intake.
There is no indication to reduce the child's fluid intake specifically in the context of Buck's traction. Adequate hydration is generally important for overall health, and fluid restriction is not a standard practice for managing Legg-Calve-Perthes disease in Buck's traction.
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