A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan to take?
Test the balloon on the indwelling urinary catheter before insertion.
Use one cotton swab to clean the client's urinary meatus.
Don sterile gloves before inserting the indwelling urinary catheter.
Apply an oil-based lubricant to the indwelling urinary catheter.
The Correct Answer is C
Choice A reason: Testing the balloon is important, but it is not the action to take immediately before insertion.
Choice B reason: While cleaning the urinary meatus is necessary, using one cotton swab is not sufficient for proper aseptic technique.
Choice C reason: Donning sterile gloves is essential to maintain an aseptic technique during catheter insertion to prevent infection.
Choice D reason: An oil-based lubricant should not be used as it can increase the risk of infection and is not compatible with the catheter material; a water-soluble lubricant is recommended.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Cerebral edema is not typically a manifestation of hyperkalemia. Hyperkalemia can cause neurological symptoms due to its effect on nerve transmission, but cerebral edema is more commonly associated with conditions like traumatic brain injury, stroke, or brain tumors.
Choice B reason: Wheezing is a respiratory symptom and is not directly related to hyperkalemia. It is more commonly associated with respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD).
Choice C reason: Hypoactive bowel sounds may indicate a gastrointestinal issue but are not a specific sign of hyperkalemia. Hyperkalemia can affect smooth muscle contraction and could potentially lead to intestinal motility issues, but this is not a primary manifestation.
Choice D reason: Decreased deep tendon reflexes can be a manifestation of hyperkalemia. Hyperkalemia affects the neuromuscular junction and can lead to muscle weakness, which may manifest as decreased reflexes. Normal potassium levels in the blood are typically between 3.5 and 5.0 millimoles per liter (mmol/L). Hyperkalemia occurs when potassium levels rise above 5.5 mmol/L.
Correct Answer is C
Explanation
The correct answer is c. "You will have a stoma placed in your right lower abdomen."
Choice A reason: The stoma should appear red and moist, similar to the inside of the mouth, not purple.
Choice B reason: The stoma does not have nerve endings, so it should not be painful.
Choice C reason: An ileostomy is typically placed in the right lower abdomen.
Choice D reason: Stool passing through an ileostomy is usually liquid to pasty, not solid.
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