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. 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.
Correct Answer is A
Explanation
A. During nasopharyngeal suctioning, the nurse should primarily focus on observing the client's skin and mucous membranes for signs of oxygenation and perfusion. This includes assessing for cyanosis, pallor, or any other signs of inadequate oxygenation.
B. Palpating the client's pedal pulses, which are pulses in the feet, is not directly relevant to nasopharyngeal suctioning. Pedal pulses are typically assessed to evaluate peripheral vascular status and circulation in the lower extremities.
C. Auscultating bowel sounds is not directly relevant to nasopharyngeal suctioning. Bowel sounds are typically assessed to evaluate gastrointestinal function and motility.
D. Assessing skin turgor elasticity is not directly relevant to nasopharyngeal suctioning. Skin turgor is typically assessed to evaluate hydration status, with decreased skin turgor often indicating dehydration.
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