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 D

Explanation

Choice A rationale

Measuring the bladder before the patient voids would not provide an accurate measurement of postvoid residual, which is the amount of urine left in the bladder after voiding.

Choice B rationale

The position of the head of the bed does not directly impact the measurement of postvoid residual. However, the patient should be in a comfortable position during the procedure.

Choice C rationale

Similar to Choice B, the position of the head of the bed does not directly impact the measurement of postvoid residual.

Choice D rationale

Measuring the bladder within 15 minutes after the patient voids allows for an accurate measurement of postvoid residual, which can help assess bladder function.

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?

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Naxlex Comprehensive Predictor Exams

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