A nurse is preparing to insert an indwelling urinary catheter for a client.
Which of the following actions should the nurse take first?
Attach a prefilled syringe to the catheter inflation hub.
Position the sterile drape leaving the perineum exposed.
Cleanse the client's meatus with antiseptic solution.
Lubricate the catheter with water-soluble gel.
The Correct Answer is C
Choice A rationale:
Attaching a prefilled syringe to the catheter inflation hub is a step performed after the catheter insertion to inflate the balloon, securing the catheter in the bladder. This action is not the first step and should not be done before cleansing the meatus and positioning the sterile drape.
Choice B rationale:
Positioning the sterile drape leaving the perineum exposed is a necessary step in maintaining the sterility of the procedure area. However, it is not the first action the nurse should take. Cleaning the client's meatus with an antiseptic solution is the initial step to prevent infection during catheter insertion.
Choice C rationale:
Cleaning the client's meatus with antiseptic solution is the first step in inserting an indwelling urinary catheter. This action helps to reduce the risk of urinary tract infection by minimizing the introduction of bacteria into the urethra.
Choice D rationale:
Lubricating the catheter with water-soluble gel is a step performed after cleansing the meatus and positioning the sterile drape. It facilitates the smooth insertion of the catheter into the urethra. However, it is not the first action to be taken.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
- A. Correct. The nurse should turn off the CPM machine during mealtime to allow the client to eat comfortably and prevent aspiration.
- B. Incorrect. The nurse should maintain the client's affected hip in a neutral position to prevent dislocation of the prosthesis and promote healing.
- C. Incorrect. The nurse should not instruct the client how to adjust the CPM settings for comfort, as this could interfere with the prescribed range of motion and speed of the device. The nurse should notify the provider if the client reports discomfort or pain.
- D. Incorrect. The nurse should not store the CPM machine under the client's bed when not in use, as this could pose a safety hazard and damage the device. The nurse should place the CPM machine on a stable surface away from the bed.
Correct Answer is D
Explanation
The nurse should not include the client's frequency of call button use in the change-of-shift report. While this information might seem relevant, it can be misinterpreted and stigmatize the client. Sharing call button frequency without context could lead assumptions about the client being overly demanding or attention-seeking, instead of focusing on their potential needs and anxieties post-surgery.
Here's why the other options are acceptable to include:
- a. The last time the provider evaluated the client:This information helps the receiving nurse stay updated on the client's clinical status and recent provider recommendations.
- b. The client's most recent ventilator settings:Although the client is weaned, knowing their past ventilator settings provides valuable insight into their respiratory function and potential risks for decompensation.
- c. The time of the client's last dose of pain medication:This helps manage the client's pain effectively and prevent potential withdrawal symptoms.
Therefore, the best answer is d. The frequency in which the client presses the call button.
Remember, a good change-of-shift report focuses on crucial clinical information relevant to the client's current condition and care plan, avoiding subjective observations that could lead to bias or misjudgment.
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