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

Use one cotton swab to clean the client's urinary meatus.

Don sterile gloves before inserting the indwelling urinary catheter.

Test the balloon on the indwelling urinary catheter before insertion.

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

Answer and Explanation

The Correct Answer is B

A. Use one cotton swab to clean the client's urinary meatus: Multiple cotton swabs should be used to clean in a systematic manner to maintain asepsis.

B. Don sterile gloves before inserting the indwelling urinary catheter. Sterile technique is essential to prevent urinary tract infections (UTIs) during catheter insertion.

C. Test the balloon on the indwelling urinary catheter before insertion: Pretesting the balloon is unnecessary and may compromise sterility or damage the balloon.

D. Apply an oil-based lubricant to the indwelling urinary catheter: Only water-based lubricants should be used to prevent catheter damage or client harm.

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Correct Answer is B

Explanation

A. Respiratory rate 28/min: A high respiratory rate suggests ongoing respiratory distress and that the intervention has not yet been effective.

B. Pink mucous membranes: Pink mucous membranes indicate adequate oxygenation and improved perfusion, showing that supplemental oxygen is effective.

C. Restlessness: Restlessness is a sign of hypoxia and indicates the oxygen therapy is not sufficient.

D. Heart rate 110/min: Tachycardia often occurs with hypoxia and does not indicate effective oxygen therapy.

A. Choose a wool blanket when using oxygen. B. Keep oxygen tanks 4 feet away from an electric stove. C. Use petroleum-based ointments to moisturize lips. D. Store oxygen tanks upright.

Correct Answer is D

Explanation

A. Choose a wool blanket when using oxygen: Wool blankets can generate static electricity, posing a fire risk. Cotton blankets are safer.

B. Keep oxygen tanks 4 feet away from an electric stove: Oxygen tanks should be kept at least 6 feet away from heat sources to reduce fire hazards.

C. Use petroleum-based ointments to moisturize lips: Petroleum-based products are flammable and should not be used near oxygen. Water-based lubricants are safer.

D. Store oxygen tanks upright: Oxygen tanks must be stored upright and secured to prevent them from tipping over, which could cause accidents or leaks.

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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 take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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