A nurse is planning to perform intermittent urinary catheterization for a client who is unable to urinate. Which of the following actions should the nurse take first?
Perform a bladder scan.
Cleanse the meatus.
Provide perineal care.
Lubricate the catheter.
The Correct Answer is A
The correct answer is choice A. Perform a bladder scan.
Choice A rationale:
Performing a bladder scan is the first action the nurse should take before proceeding with intermittent urinary catheterization. A bladder scan assesses the bladder's volume and determines if catheterization is necessary. It helps avoid unnecessary catheterizations, reduces the risk of infection, and promotes patient comfort.
Choice B rationale:
While cleansing the meatus and providing perineal care are important steps in preparing for urinary catheterization, they come after assessing the need for catheterization. Without knowing the bladder volume, these actions could be premature.
Choice C rationale:
Providing perineal care is important for maintaining hygiene and preventing infection, but it should be done after the decision for catheterization has been made based on the bladder scan results.
Choice D rationale:
Lubricating the catheter is a step that should be taken after the decision for catheterization is made and the need for catheterization is confirmed. It helps ease the insertion process and reduce discomfort for the patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
"You will need to sign a consent form before we begin the procedure." Rationale: While obtaining consent is an essential part of many medical procedures, including a bladder scan, it is not specific to the teaching related to the procedure itself. It addresses the legal and ethical aspect of the procedure but doesn't instruct the client on what to expect during the procedure.
Choice B rationale:
"I will place a gel pad directly above your pubic area before I place the probe." Rationale: This is the correct choice. Placing a gel pad above the pubic area before using the probe is an important step in ensuring proper ultrasound transmission and obtaining accurate results during a bladder scan. The gel pad helps to eliminate air gaps that could interfere with the quality of the scan.
Choice C rationale:
"You will need to hold your urine for 1 hour prior to the procedure." Rationale: Holding urine for an hour before a bladder scan might be required to ensure that the bladder is adequately filled for the scan, but it doesn't address the specific preparation related to the ultrasound procedure itself.
Choice D rationale:
"You will receive a contrast dye through an IV catheter prior to the scan." Rationale: Mentioning contrast dye and IV catheter is not relevant to a bladder scan. Contrast dye is often used in imaging studies like CT scans or angiograms, but not for a routine bladder scan. Therefore, this instruction is unrelated to the procedure in question.
Correct Answer is C
Explanation
The correct answer is choicec. Release of personal belongings form.
Choice A rationale:
Completion of an incident report is not typically part of postmortem care documentation unless there was an unusual or unexpected event surrounding the death.
Choice B rationale:
While the name of the nurse certifying the client’s death is important, it is usually documented separately in the death certificate or other official records, not necessarily in the postmortem care documentation.
Choice C rationale:
The release of personal belongings form is crucial as it ensures that the client’s belongings are properly accounted for and handed over to the appropriate person, providing a clear record of what was released and to whom.
Choice D rationale:
Documenting one client identifier at the time of death is important, but it is not specific to postmortem care documentation. Identifiers are generally used throughout the client’s medical record to ensure accuracy and consistency.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today