The nurse is inserting a urinary catheter that has been prescribed for the client. When the tip of the catheter reemerges from the insertion site, which action should the nurse take next?

Increase the lighting in the room.

Obtain a new catheter.

Clean the catheter with providone-iodine.

Reposition the legs before reinsertion.

Answer and Explanation

The Correct Answer is B

B. If the tip of the urinary catheter reemerges from the insertion site during insertion, it means that the catheter has become contaminated with microorganisms from the urethra or surrounding area. Continuing to insert the same catheter can introduce these microorganisms into the urinary tract, increasing the risk of urinary tract infection (UTI).

A. Increasing the lighting in the room allows for optimal visualization during the procedure, but it is not the priority action when the catheter has become contaminated.

C. Cleaning the catheter with providone-iodine is not sufficient to sterilize the catheter and eliminate the risk of introducing pathogens into the urinary tract.

D. Repositioning the legs before reinsertion does not address the contamination of the catheter and does not mitigate the risk of introducing pathogens into the urinary tract.

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Correct Answer is D

Explanation

A chart by exception system requires nurses to document deviations from the expected or normal findings rather than documenting every single detail.

D All lung zones should have clear vesicular breath sounds. The presence of diminished sounds indicated lung consolidation which can occur in pneumonic processes or pleural effecusion.

A This finding indicates a normal response known as a consensual response, where the left pupil constricts when light is shone into the right eye.

B Active bowel sounds are considered normal and indicate proper gastrointestinal motility.

C Capillary refill is a quick bedside test used to assess peripheral circulation and tissue perfusion. A refill time of 2 seconds is within the normal range (typically 2 seconds or less), indicating adequate perfusion.

A. Living will becomes invalid when receiving hospice care. B. Hospice services can be initiated prior to discharge. C. Family members can be involved in the plan of care. D. Provides comfort, dignity, and emotional support. E. Can be provided within comforts of home.

Correct Answer is ["B","C","D","E"]

Explanation

B. Hospice services can be initiated while the client is still in the hospital. Hospice teams can work alongside the hospital staff to provide care and support to the client and family during the transition to hospice care.
C. Hospice care emphasizes the involvement of family members in the care of the patient. The hospice team works with the patient and family to develop a personalized plan of care that addresses the physical, emotional, and spiritual needs of the patient and family members.
D. Hospice care focuses on providing comfort, maintaining dignity, and offering emotional support to patients with terminal illnesses and their families. The goal is to enhance quality of life and ensure that the patient's wishes and preferences are respected throughout the end-of- life process.
E. Hospice care can be provided in various settings, including the patient's own home, assisted living facilities, nursing homes, or inpatient hospice units. The option to receive care in the comfort of home is often preferred by many patients and families as it allows them to remain in familiar surroundings surrounded by loved ones.

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The nurse is inserting a urinary catheter that has been prescribed for the client. When the tip of the catheter reemerges from the insertion site, which action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?

Correct Answer is D

Explanation

A female client with metastatic breast cancer is admitted with shortness of breath and pleural effusions. The client has a living will and the family is requesting hospice information. Which information should the nurse provide regarding hospice? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

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