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
Choice A rationale:
Hypothermia, or abnormally low body temperature, is not typically a symptom of diarrhea. While it’s possible for a person with severe diarrhea to experience chills or feel cold, hypothermia is not a direct result of diarrhea.
Choice B rationale:
A rigid abdomen is often a sign of a serious condition like peritonitis (inflammation of the peritoneum, the tissue that lines the inner wall of the abdomen), but it is not typically associated with diarrhea.
Choice C rationale:
Dehydration is a common complication of diarrhea. When a person has diarrhea, they can lose a lot of fluid and electrolytes quickly, leading to dehydration. Symptoms of dehydration can include thirst, less frequent urination, dark-colored urine, fatigue, dizziness, and confusion.
Choice D rationale:
Decreased bowel sounds are not typically associated with diarrhea. In fact, bowel sounds may actually increase in some cases of diarrhea due to increased gut motility.
Correct Answer is ["A","C"]
Explanation
The correct answers are Choices A and C.
Choice A rationale: Ignoring the urge to defecate can lead to constipation because the longer stool remains in the colon, the more water is absorbed from it, making it harder and more difficult to pass. This can lead to a cycle of further constipation and discomfort.
Choice B rationale: Increased fiber in the diet usually helps prevent constipation by adding bulk to the stool and making it easier to pass. Therefore, it is not a cause of constipation, but rather a preventive measure.
Choice C rationale: Excessive laxative use can lead to dependence on laxatives for bowel movements and can disrupt normal bowel function. Over time, this can lead to constipation as the bowel becomes less responsive to normal stimuli.
Choice D rationale: Increased activity generally helps to prevent constipation by stimulating bowel motility. Physical exercise can enhance the efficiency of the digestive system, so it is not a cause of constipation.
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