Try Naxlex NCLEX-RN (Free-Trial)

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 B

Correct Answer: B. Position the sterile drape leaving the perineum exposed.

Rationales

A. Lubricate the catheter with water-soluble gel.
Lubrication is important to reduce urethral trauma, but this is not the first step once the sterile field is prepared. It comes after draping and cleansing, just before catheter insertion.

B. Position the sterile drape leaving the perineum exposed.
This is the first action after donning sterile gloves and preparing the field. Draping maintains a sterile environment and provides access to the insertion site. Ensuring sterility from the beginning is critical for preventing catheter-associated infections.

C. Cleanse the client’s meatus with antiseptic solution.
Cleansing the meatus is done after draping to reduce the risk of introducing microorganisms during catheter insertion. Although essential, it is not the very first step once the sterile procedure begins.

D. Attach a prefilled syringe to the catheter inflation hub.
The balloon should not be prepared or inflated until after the catheter has been inserted and urine return is observed. Attaching the syringe too early may risk accidental inflation outside the bladder.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Hearing loss: While digoxin toxicity can affect various organ systems, including the auditory system, resulting in symptoms such as tinnitus (ringing in the ears), hearing loss is not a typical manifestation of digoxin toxicity.
B. Insomnia: Insomnia is not a common symptom of digoxin toxicity. Clients with digoxin toxicity are more likely to experience neurological symptoms such as confusion, visual disturbances, or changes in mental status.
C. Tachycardia: Digoxin toxicity can cause arrhythmias, but it typically presents with bradycardia rather than tachycardia. Bradycardia is a hallmark sign of digoxin toxicity due to its negative chronotropic effect on the heart.
D. Blurred vision: Blurred or yellow-tinted vision is a classic symptom of digoxin toxicity, often described as "yellow halos" around lights. Visual disturbances occur due to the drug's effects on the optic nerve and can progress to more severe manifestations, such as changes in color vision or photophobia. Therefore, blurred vision is a key indicator of digoxin toxicity and requires prompt assessment and intervention.

A. "Hold your daughter when your son first meets her." B. "Plan for your son to meet his sister for the first time at home." C. "Give your son a little gift from his new sister." D. "Give your son plenty of 'alone time' with his sister."

Correct Answer is C

Explanation

A. "Hold your daughter when your son first meets her." While it is important for the mother to hold the newborn during the first meeting with the older sibling, this option does not directly address the preschool-age son's potential reaction to the new baby.
B. "Plan for your son to meet his sister for the first time at home." Planning for the first meeting to occur at home is a common and appropriate strategy to help ease the transition for the older sibling. However, this option does not provide a specific strategy for helping the preschool-age son adjust to having a new sister.
C. "Give your son a little gift from his new sister." This is the most appropriate strategy to suggest. Offering a small gift from the new baby sister can help the preschool-age son feel included and special, fostering positive feelings toward the new sibling.
D. "Give your son plenty of 'alone time' with his sister." While encouraging bonding time between siblings is important, giving the older sibling plenty of alone time with the new baby may not be practical or feasible, especially in the early postpartum period when the mother requires assistance with caring for the newborn. Moreover, this option does not address the son's potential feelings of adjustment to having a new sister.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Correct Answer: B. Position the sterile drape leaving the perineum exposed.

Rationales

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is taking digoxin to treat chronic heart failure. Which of the following findings should indicate to the nurse that the client is developing digoxin toxicity?

Correct Answer is D

Explanation

A nurse is caring for a client who is postpartum and expresses concern about how her preschool-age son will react to having a baby sister. Which of the following strategies should the nurse suggest?

Correct Answer is C

Explanation

A nurse is documenting admission data for a client on an acute care facility. Which of the following actions should the nurse take?

A nurse is performing an admission assessment of a school-age child who has spina bifida. The parent states that the child is allergic to latex. The nurse should assess further for cross-sensitivity to which of the following foods?

A nurse is providing discharge teaching to a client who has GERD. Which of the following information should the nurse include?

A nurse is assessing a client who is in mechanical restraints after Hitting a staff member. Which of the following findings indicates that the nurse should discontinue the restraints?

A nurse is providing dietary teaching to the guardian of a preschooler who has celiac disease. Which of the following foods should the nurse recommend including in the preschooler's diet?

A nurse is reviewing the medical record of a client who has a prescription for misoprostol for induction of labor. Which of the following findings is a contraindication for administration of this medication?

A nurse is planning care for a client who is experiencing benzodiazepine toxicity. The nurse should plan to administer which of the following medications?

A nurse is assessing a client who is receiving enteral feedings via ah NG tube. The client has developed hyperosmolar dehydration. Which of the following actions should the nurse take when administering the client's feedings?