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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 take first?

Lubricate the catheter with water-soluble gel.

Position the sterile drape leaving the perineum exposed.

Cleanse the client's meatus with antiseptic solution.

Attach a prefilled syringe to the catheter inflation hub.

None

Answer and Explanation

The Correct Answer is C

Answer: C. Cleanse the client's meatus with antiseptic solution.

Rationale:

A. Lubricate the catheter with water-soluble gel:
While lubrication is an important step in the catheterization process, it is not the first action to take. Proper cleansing of the meatus is essential to minimize the risk of introducing bacteria into the urinary tract during the insertion of the catheter.

B. Position the sterile drape leaving the perineum exposed:
Setting up the sterile field is crucial, but the first priority should be to cleanse the meatus to prevent infection. The sterile drape should be positioned after ensuring the area is clean and before catheter insertion.

C. Cleanse the client's meatus with antiseptic solution:
This is the first action the nurse should take. Properly cleansing the meatus with antiseptic solution helps reduce the risk of urinary tract infections by eliminating bacteria from the area prior to catheter insertion. It is a critical step in maintaining aseptic technique during the procedure.

D. Attach a prefilled syringe to the catheter inflation hub:
Attaching the syringe for inflation is done after the catheter is inserted and positioned correctly. This action comes later in the procedure, once aseptic measures have been completed and the catheter is in place.

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Correct Answer is B

Explanation

A. Performing a simple dressing change on a client's foot - This action is appropriate and within the scope of practice for assistive personnel.
B. Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile - Handwashing with alcohol-based hand rub is not effective against Clostridium difficile spores. Proper hand hygiene for C. difficile requires washing with soap and water. The charge nurse should intervene to correct this action and ensure proper infection control procedures are followed.
C. Providing postmortem care for a client who has recently died - Providing postmortem care is within the scope of practice for assistive personnel and is appropriate.
D. Emptying an indwelling urinary catheter bag for a client while wearing clean gloves - This action is appropriate and within the scope of practice for assistive personnel.

A. "I'll replace the batteries every 2 weeks." B. "I'll use isopropyl alcohol to clean my hearing aids." C. "I'll clean my ear with cotton swabs before I insert my hearing aids." D. "It will disconnect the battery when I remove my hearing aids."

Correct Answer is D

Explanation

A. "I'll replace the batteries every 2 weeks." - This statement is incorrect. While it's essential to replace hearing aid batteries regularly, the frequency of battery replacement depends on factors such as battery type, usage, and the specific needs of the individual. Providing a specific timeframe like "every 2 weeks" may not be accurate for all clients.
B. "I'll use isopropyl alcohol to clean my hearing aids." - This statement is incorrect. Isopropyl alcohol can damage hearing aids as it may degrade plastic components or affect the adhesives used in their construction. Instead, clients should use a soft, dry cloth or a specialized hearing aid cleaning tool recommended by their audiologist.
C. "I'll clean my ear with cotton swabs before I insert my hearing aids." - This statement is incorrect. Using cotton swabs to clean the ear canal can push earwax deeper into the ear canal, potentially impacting it and interfering with hearing aid function. Clients should avoid inserting anything into their ear canal and consult with their healthcare provider if earwax buildup is a concern.
D. "It will disconnect the battery when I remove my hearing aids." - This statement is correct. Many behind-the-ear (BTE) hearing aids are designed to disconnect the battery when removed from the ear, helping to conserve battery life when not in use. This understanding indicates that the client grasps an essential aspect of caring for their hearing aids.

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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 take first?

Rationale:

Nursing Test Bank

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