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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Full-thickness skin loss with visible bone is characteristic of a stage 4 pressure injury, not a stage 1 pressure injury.

Choice B rationale

Full-thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury, not a stage 1 pressure injury.

Choice C rationale

In a stage 1 pressure injury, the skin remains intact with localized erythema. The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue.

Choice D rationale

Partial-thickness skin loss with red tissue in the wound bed is characteristic of a stage 2 pressure injury, not a stage 1 pressure injury.

A. Troponin. B. Albumin. C. Total bilirubin. D. Creatine kinase.

Correct Answer is B

Explanation

Choice A rationale

Troponin is a cardiac enzyme which indicates a client has experienced a myocardial infarction. It is not a laboratory test that supports a diagnosis of malnutrition.

Choice B rationale

Albumin is a measure of plasma proteins which reflects the nutritional condition of a client experiencing anorexia and malnutrition over an extended period of time. Therefore, a nurse

should expect altered albumin levels in a client who reports anorexia and is experiencing malnutrition.

Choice C rationale

Total bilirubin is altered in clients who are experiencing hepatobiliary disease. It is not a laboratory test that supports a diagnosis of malnutrition.

Choice D rationale

Creatine kinase is a cardiac enzyme which is useful in the diagnosis of a myocardial infarction. It is not a laboratory test that supports a diagnosis of malnutrition.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is evaluating a patient who has a stage 1 pressure injury. What findings should the nurse anticipate?

Correct Answer is C

Explanation

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?

Correct Answer is B

Explanation

A nurse is teaching a client who has urinary incontinence about avoiding foods and beverages that can cause bladder irritation.Which of the following foods and beverages is a bladder irritant?

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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?

A nurse is assessing a patient’s wound dressing and observes a watery red drainage. How should the nurse document this type of drainage?

A nurse finds that the infusion pump for a patient’s total parenteral nutrition (TPN) solution is not working. What condition should the nurse monitor the patient for?

A nurse is caring for a patient who is receiving enteral tube feeding and has a new prescription to dilute the formula. The nurse recognizes this is being done to resolve which of the following conditions?

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?