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

Cleanse the urethral meatus.

Apply sterile gloves.

Attach the pre-filled syringe to the inflation bulb.

Saturate the cotton balls with antiseptic.

Answer and Explanation

The Correct Answer is B

A. Cleanse the urethral meatus. This step occurs after preparing the sterile field and donning sterile gloves.
B. Apply sterile gloves. This is correct. The first step in the standardized procedure is to apply sterile gloves to maintain aseptic technique throughout the catheter insertion process.
C. Attach the pre-filled syringe to the inflation bulb. This step is part of the preparation but comes after the sterile gloves are applied.
D. Saturate the cotton balls with antiseptic. This step occurs after donning sterile gloves.

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Correct Answer is C

Explanation

A. Fresh vegetables Fresh vegetables are generally not associated with triggering migraines.
B. Frozen yogurt While some people may have individual triggers, frozen yogurt is not a common migraine trigger.
C. Red wine: Red wine contains tyramine, which is known to trigger migraines in many people.
D. Orange juice Orange juice is not commonly associated with triggering migraines.

A. Assist the client to make autonomous decisions about his treatment options. B. Reflect on her own opinion about withholding the diagnosis from him. C. Inform the family that he has a legal right to be informed of his diagnosis. D. Determine the family's reasons for not telling him about his diagnosis.

Correct Answer is D

Explanation

A. Assist the client to make autonomous decisions about his treatment options. Assisting the client to make autonomous decisions is important, but it cannot be done effectively until the client is aware of his diagnosis. This action would follow once the client is informed.
B. Reflect on her own opinion about withholding the diagnosis from him. Reflecting on her own opinion can help the nurse understand her biases but does not directly address the family's request or the client's immediate needs.
C. Inform the family that he has a legal right to be informed of his diagnosis. Informing the family about the client's legal right is essential, but first, the nurse should understand the family's perspective and concerns.
D. Determine the family's reasons for not telling him about his diagnosis. This is correct. Understanding the family's reasons provides context and helps the nurse address their concerns appropriately while advocating for the client’s right to know his diagnosis.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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