A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan to take?

Don sterile gloves before inserting the indwelling urinary catheter.

Apply an oil-based lubricant to the indwelling urinary catheter.

Use one cotton swab to clean the client’s genitalia.

Test the balloon on the indwelling urinary catheter before insertion.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Donning sterile gloves before inserting the indwelling urinary catheter is a critical step to prevent infection. The urinary tract is normally sterile, and using sterile gloves helps maintain this sterility during the procedure.

Choice B rationale

Applying an oil-based lubricant to the indwelling urinary catheter is not recommended. Oil- based lubricants can damage latex catheters and increase the risk of infection. A water-soluble lubricant is typically used.

Choice C rationale

Using one cotton swab to clean the client’s genitalia is not sufficient. Proper cleaning and disinfection of the area are crucial to prevent introducing bacteria into the urinary tract during catheter insertion.

Choice D rationale

Testing the balloon on the indwelling urinary catheter before insertion is not typically done. The balloon is usually inflated with sterile water once the catheter is in place to ensure that it remains in the bladder.

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Correct Answer is B

Explanation

Choice A rationale

Visual aids can be very helpful for patients with impaired speech. They can use pictures, written words, or devices to help express their thoughts2324.

Choice B rationale

Allowing extra time to communicate with the patient is crucial. It can reduce frustration and improve the effectiveness of communication2324.

Choice C rationale

Completing sentences for the patient can be disrespectful and may not accurately convey the patient’s thoughts2324.

Choice D rationale

Asking open-ended questions can be challenging for a person with impaired speech. It’s better to ask yes/no questions or use other communication strategies2324.

A. To remove gastric acid that might cause dyspepsia B. To identify delayed gastric emptying C. To determine the patient’s electrolyte balance D. To confirm the placement of the NG tube

Correct Answer is B

Explanation

Choice A rationale

While gastric acid can cause dyspepsia, measuring gastric residual is not primarily done to remove gastric acid.

Choice B rationale

Measuring gastric residual is primarily done to identify delayed gastric emptying. This is important because delayed gastric emptying can lead to complications such as aspiration pneumonia.

Choice C rationale

Gastric residual does not directly determine the patient’s electrolyte balance.

Choice D rationale

While confirming the placement of the NG tube is important, it is not the primary purpose of measuring gastric residual.

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A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who has impaired speech. What actions should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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