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.
Test the balloon on the indwelling urinary catheter before insertion.
Use one cotton swab to clean the client's urinary meatus.
The Correct Answer is A
Choice A reason: Donning sterile gloves is an essential step to prevent contamination and infection during the insertion of an indwelling urinary catheter. The nurse should also use aseptic technique and a sterile catheter kit.
Choice B reason: Applying an oil-based lubricant to the indwelling urinary catheter is not recommended, as it can damage the latex material and increase the risk of catheter-associated urinary tract infection (CAUTI). The nurse should use a water-soluble lubricant instead.
Choice C reason: Testing the balloon on the indwelling urinary catheter before insertion is a good practice, as it ensures that the balloon is functioning properly and does not leak or burst. The nurse should inflate and deflate the balloon with sterile water or saline using a syringe.
Choice D reason: Using one cotton swab to clean the client's urinary meatus is not sufficient, as it may not remove all the bacteria and debris. The nurse should use at least three cotton swabs and clean the meatus from front to back in a circular motion. The nurse should also use an antiseptic solution such as chlorhexidine or povidone-iodine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Tachycardia is not an adverse effect of oxygen therapy. Tachycardia is a condition where the heart rate is faster than normal, usually above 100 beats per minute. Tachycardia can be caused by various factors, such as fever, infection, pain, or anxiety. Tachycardia can also be a sign of hypoxemia, which is a low level of oxygen in the blood, and may indicate the need for oxygen therapy.
Choice B reason: Cracks in oral mucous membranes are an adverse effect of oxygen therapy. Cracks in oral mucous membranes are a sign of dryness and irritation caused by the oxygen flow. Oxygen therapy can reduce the natural moisture and lubrication of the mouth and nose, leading to discomfort and increased risk of infection. To prevent or treat this problem, the nurse should provide the client with humidified oxygen, oral care, and hydration.
Choice C reason: Excessive pulmonary secretions are not an adverse effect of oxygen therapy. Excessive pulmonary secretions are a sign of inflammation and infection in the lungs, which can impair gas exchange and cause coughing, wheezing, and dyspnea. Excessive pulmonary secretions can be a symptom of pneumonia, which is a common cause of respiratory failure and may require oxygen therapy.
Choice D reason: Poor skin turgor is not an adverse effect of oxygen therapy. Poor skin turgor is a sign of dehydration, which is a loss of fluid from the body. Dehydration can be caused by various factors, such as vomiting, diarrhea, fever, or inadequate intake. Dehydration can affect the blood volume and pressure, and may worsen the oxygen delivery to the tissues. To prevent or treat this problem, the nurse should monitor the client's fluid balance and provide adequate hydration.
Correct Answer is A
Explanation
Choice A reason: The pulmonary artery is the large blood vessel that carries deoxygenated blood from the right ventricle to the lungs for gas exchange. It is the only artery that carries deoxygenated blood in the body.
Choice B reason: The pulmonary veins are the blood vessels that carry oxygenated blood from the lungs to the left atrium. They are the only veins that carry oxygenated blood in the body.
Choice C reason: The left ventricle is the chamber of the heart that pumps oxygenated blood to the rest of the body through the aorta. It does not directly connect to the lungs.
Choice D reason: The left atrium is the chamber of the heart that receives oxygenated blood from the pulmonary veins. It does not directly connect to the right ventricle.
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