A nurse is inserting a catheter into a female patient. When the nurse inserts the catheter, no urine is obtained. The nurse suspects the catheter is not in the urethra.
What should the nurse do?
Fill the balloon with the recommended sterile water.
Remove the catheter, wipe with alcohol, and reinsert after lubrication.
Leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter.
Discard the catheter and begin again.
The Correct Answer is C
If the nurse suspects the catheter is not in the urethra, they should leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Wet-to-dry dressings are a form of mechanical debridement. This method involves applying a wet dressing to the wound and allowing it to dry. When the dressing is removed, it also removes some of the dead or damaged tissue from the wound, helping to clean the wound and promote healing. This method can be painful and is not selective, meaning it can also remove healthy tissue. However, it is often used for wounds with a large amount of debris or necrotic tissue.
Choice B rationale: Surgical debridement is another method of wound debridement, but it is not a form of mechanical debridement. This method involves using surgical instruments to remove dead or damaged tissue. It is the fastest method of debridement and is often used for wounds that are infected or have a large amount of necrotic tissue. However, it requires a skilled practitioner and can be painful.
Choice C rationale: Enzymatic debridement involves applying a topical ointment that contains enzymes to the wound. These enzymes help to break down dead or damaged tissue. This method is selective and only removes necrotic tissue, leaving healthy tissue intact. However, it is not a form of mechanical debridement.
Choice D rationale: Autolytic debridement is a method that uses the body’s own enzymes and moisture to break down dead or damaged tissue. This is the slowest method of debridement but is also the least painful and is selective for necrotic tissue. Like enzymatic debridement, autolytic debridement is not a form of mechanical debridement.
Correct Answer is ["125"]
Explanation
Step 1 is to understand the question. The patient has been prescribed vancomycin 1 g in 250 mL dextrose 5% (D5W) to be administered over 2 hours via IV intermittent bolus. We need to calculate how many mL/hr the nurse should set the IV pump to deliver.
Step 2 is to calculate the rate. The total volume to be administered is 250 mL and the time for administration is 2 hours. So, the rate is 250 mL ÷ 2 hours = 125 mL/hr.
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