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 ["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","D"]
Explanation
Choice A rationale:
Crackles are a common symptom of pleural effusion. They are abnormal lung sounds that are heard when a patient with pleural effusion breathes in. The sound is caused by the opening of small airways and alveoli collapsed by fluid, exudate, or lack of aeration during expiration.
Choice B rationale:
Crepitus is not typically associated with pleural effusion. Crepitus is a crackling or grating sound or feeling produced by air in subcutaneous tissue or by the rubbing together of fragments of broken bone. In the context of respiratory health, crepitus might be felt if there is subcutaneous emphysema, where air gets into tissues under the skin covering the chest wall or neck.
Choice C rationale:
Substernal retractions are not a typical symptom of pleural effusion. Retractions are a sign of respiratory distress, but they are more commonly associated with conditions that cause upper airway obstruction or severe lung disease, such as asthma or pneumonia. Choice D rationale:
Dullness upon percussion is a classic sign of pleural effusion. When there is fluid in the pleural space, it prevents the normal resonant sound produced by the air-filled lungs from being heard. Instead, a dull sound is heard when the chest is percussed.
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