A nurse is preparing to insert an indwelling urinary catheter for a patient.
What 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 patient’s urinary meatus.
Correct Answer : A,C,D
Choice A rationale:
Donning sterile gloves before inserting the indwelling urinary catheter is a standard practice in healthcare to prevent infection. The urinary tract is normally sterile, and the use of sterile gloves helps maintain this sterility during the catheter insertion process. Choice B rationale:
Oil-based lubricants should not be used with indwelling urinary catheters. These lubricants can damage the catheter material and increase the risk of infection. Instead, water-soluble lubricants are recommended as they do not damage the catheter and can reduce patient discomfort during the insertion process.
Choice C rationale:
Testing the balloon on the indwelling urinary catheter before insertion is a critical step. This is done to ensure that the balloon inflates and deflates properly. If the balloon does not function correctly, it could cause discomfort or injury to the patient during insertion and could fail to keep the catheter in place once inserted.
Choice D rationale:
Cleaning the patient’s urinary meatus with one cotton swab is a part of the standard procedure before inserting an indwelling urinary catheter. This step is taken to remove any bacteria present at the site of insertion, thereby reducing the risk of introducing bacteria into the bladder during the catheter insertion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C"]
Explanation
The correct answer is Choice C.
Choice A rationale: Applying four drops of developing solution to each stool specimen is incorrect. Typically, the test requires two drops of solution. Following manufacturer instructions ensures accurate results and prevents unnecessary waste or inaccurate readings.
Choice B rationale: Using toilet paper to transfer the stool specimen is improper. Stool should be collected using the provided applicator stick to avoid contamination, ensuring the accuracy of the fecal occult blood test.
Choice C rationale: Waiting 30 seconds after applying the developing solution allows the chemical reaction to complete, ensuring accurate detection of any occult blood present in the stool sample.
Choice D rationale: Collecting two stool specimens from the same area increases the risk of missing occult blood present in different parts of the stool. Sampling from multiple areas enhances test accuracy and ensures comprehensive results.
Correct Answer is A
Explanation
The correct answer is choice A.
Choice A rationale: Assisting the patient to the bathroom every 2 hours is a fixed schedule that doesn't allow for individual variations in bladder function. A bladder-training program should encourage the patient to recognize and respond to their own urge to urinate, promoting self-reliance and bladder control.
Choice B rationale: Offering the opportunity to urinate before bathing is a good practice to prevent accidents and promote comfort. It also helps to reduce the risk of urinary tract infections.
Choice C rationale: Encouraging the patient to urinate when they feel the urge is a key component of bladder training. It helps the patient to develop bladder control and reduce the frequency of accidents.
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