A nurse is preparing to insert an indwelling urinary catheter for a client.
Which of the following actions should the nurse take first?
Attach a prefilled syringe to the catheter inflation hub.
Position the sterile drape leaving the perineum exposed.
Cleanse the client's meatus with antiseptic solution.
Lubricate the catheter with water-soluble gel.
The Correct Answer is C
Choice A rationale:
Attaching a prefilled syringe to the catheter inflation hub is a step performed after the catheter insertion to inflate the balloon, securing the catheter in the bladder. This action is not the first step and should not be done before cleansing the meatus and positioning the sterile drape.
Choice B rationale:
Positioning the sterile drape leaving the perineum exposed is a necessary step in maintaining the sterility of the procedure area. However, it is not the first action the nurse should take. Cleaning the client's meatus with an antiseptic solution is the initial step to prevent infection during catheter insertion.
Choice C rationale:
Cleaning the client's meatus with antiseptic solution is the first step in inserting an indwelling urinary catheter. This action helps to reduce the risk of urinary tract infection by minimizing the introduction of bacteria into the urethra.
Choice D rationale:
Lubricating the catheter with water-soluble gel is a step performed after cleansing the meatus and positioning the sterile drape. It facilitates the smooth insertion of the catheter into the urethra. However, it is not the first action to be taken.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
- A is incorrect because it is an example of self-disclosure, not altruism. Self-disclosure is sharing personal information or feelings with others.
- B is incorrect because it is an example of jealousy, not altruism. Jealousy is feeling threatened or resentful by someone else's success or happiness.
- C is correct because it is an example of altruism, which is helping others without expecting anything in return. Altruism can enhance self-esteem and coping skills for clients who have breast cancer.
- D is incorrect because it is an example of trust, not altruism. Trust is believing that someone is reliable and honest.
Correct Answer is A
Explanation
- A. Pink, frothy sputum is a characteristic finding of pulmonary edema, which is caused by fluid accumulation in the alveoli and interstitial spaces of the lungs. This impairs gas exchange and leads to hypoxia and respiratory distress.
- B. Bradycardia is not expected in pulmonary edema. The client is more likely to have tachycardia due to increased sympathetic stimulation and decreased cardiac output.
- C. Flushed, dry skin is not expected in pulmonary edema. The client is more likely to have pale, cool, and clammy skin due to peripheral vasoconstriction and decreased perfusion.
- D. Wheezing is not a specific finding of pulmonary edema. It may indicate bronchospasm or asthma, which are different conditions that affect the airways rather than the alveoli.
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