A nurse is teaching a newly licensed nurse about the function of the large intestine. Which of the following information should the nurse include?
It produces vitamin D.
It absorbs liquid to form stool.
It prevents the reflux of food into the esophagus.
It secretes enzymes to digest food.
The Correct Answer is B
A. The nurse coats the indwelling urinary catheter with lubricant. This is correct procedure and requires no intervention. Lubricating the catheter reduces friction and discomfort during insertion.
B. The nurse applies the sterile drape prior to inserting the urinary catheter. This is correct procedure and requires no intervention. The sterile drape maintains a sterile field.
C. The nurse separates the client's labia with her dominant hand. The nurse should separate the client's labia with her non-dominant hand, which then remains in place as a "dirty" hand. The dominant hand, which remains sterile, is used to insert the catheter.
D. The nurse provides perineal care prior to inserting the urinary catheter. This is correct procedure and requires no intervention. Perineal care reduces the risk of introducing bacteria into the urinary tract.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Moist skin: Dehydration typically causes dry skin due to reduced fluid volume, not moist skin. This finding is not expected in a dehydrated client.
B. Dark-colored urine: Dark-colored urine is a common sign of dehydration, as the urine becomes more concentrated when the body conserves water. This finding is expected.
C. Distended neck veins: Dehydration typically causes flat or collapsed neck veins due to decreased blood volume. Distended neck veins are more associated with fluid overload or heart failure. This finding is not expected.
D. High blood pressure: Dehydration often leads to low blood pressure due to reduced blood volume. High blood pressure is not typically associated with dehydration.
Correct Answer is C
Explanation
A. Body Image: Body image stressors relate to how a person perceives their physical self. This is not relevant to the scenario of work and family stress.
B. Self-esteem: Self-esteem stressors relate to a person’s sense of self-worth. While stress from work and family can affect self-esteem, the primary issue here is more related to role performance.
C. Role performance: Role performance stressors relate to how well an individual perceives they are fulfilling their roles in life, such as work, parenting, or caregiving. The client’s stress about balancing work and family responsibilities indicates a role performance issue. This is the correct answer.
D. Identity: Identity stressors involve a person’s sense of who they are. While stress from work and family can affect identity, the primary issue here is more specifically related to role performance.
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