A nurse is preparing to remove a patient’s urinary catheter.
After performing hand hygiene, what should the nurse do next?
Position the client supine.
Cleanse the perineal area with an antiseptic.
Deflate the balloon halfway and then pull out the catheter.
Have the client bear down during removal.
The Correct Answer is B
Choice A rationale:
Positioning the client supine is not the immediate next step after performing hand hygiene when preparing to remove a patient’s urinary catheter. While it is important to ensure the patient is in a comfortable and appropriate position for the procedure, the immediate next step should be focused on ensuring the area is clean to prevent infection.
Choice B rationale:
After performing hand hygiene, the nurse should cleanse the perineal area with an antiseptic. This is to ensure that the area is clean before proceeding with the removal of the urinary catheter. It helps to prevent the introduction of bacteria into the urinary tract, which could lead to a urinary tract infection. The use of an antiseptic is recommended to kill any potential pathogens that may be present.
Choice C rationale:
Deflating the balloon halfway and then pulling out the catheter is not the immediate next step after performing hand hygiene. This step is usually done later in the process. Before deflating the balloon, it is important to ensure that the area is clean to prevent infection. Moreover, deflating the balloon halfway could potentially cause discomfort or injury to the patient. The balloon should be fully deflated before the catheter is removed.
Choice D rationale:
Having the client bear down during removal is not the immediate next step after performing hand hygiene. This action might be suggested during the actual removal of the catheter to aid in the process, but it is not the immediate next step. The focus right after hand hygiene should be on cleaning the area to prevent infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale:
Spinach is one of the most nutrient-dense vegetables. Just 1 cup (190 grams) of frozen spinach packs 12% of the DV for potassium. It’s also loaded with other nutrients. The same serving of frozen spinach contains 127% of the DV for vitamin A, 857% for vitamin K, 58% for folate, and 37% for magnesium.
Choice B rationale:
Potatoes are a staple food and are high in potassium. They are a versatile and filling food that can be included in a variety of dishes. Potatoes are also a good source of vitamin C and dietary fiber.
Choice C rationale:
Bananas are known as potassium-rich foods. A medium banana contains around 9% of the DV for this mineral. Most people consider it the go-to food to increase their potassium intake. However, bananas are not the only good source of potassium.
Choice D rationale:
Apples are a healthy choice and provide some potassium, but they are not as high in potassium as the other choices. Therefore, while apples are a good part of a balanced diet, they would not be the first recommendation for someone needing to increase their potassium intake.
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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