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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. The needle should be inserted with the bevel facing up (visible through the skin). The goal is to deposit the medication into the epidermal layer (not subcutaneous tissue).
A. Massaging the site after injection can cause the medication to spread beyond the intended area, leading to inaccurate results or potential complications.
C. The correct angle for an intradermal injection is 5 to 15-degree angle. This angle allows for proper placement of the medication just below the epidermis.
D. Intradermal injections are usually administered on the forearm or the upper back, where the skin is thin and easily lifted to create a wheal.
Correct Answer is D
Explanation
D. This area is commonly used for LMWH injections due to its high vascularity and absorption rate. Injecting at least 2 inches away from the umbilicus helps minimize the risk of injury to the umbilical vessels and ensures proper absorption of the medication.
A. Massaging the injection site is not recommended after administering LMWH because it can increase the risk of bruising, bleeding, or tissue damage.
B. LMWH injections are typically administered in the abdomen, with sites rotated within the same area. While rotating between the abdomen and gluteal areas may be appropriate for some medications, LMWH is generally administered in the abdomen only.
C. If you expel the air bubbles before injecting, you might inadvertently expel a small amount of insulin along with the air. This could result in receiving less insulin than intended.
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