The nurse is planning to care for a client with an indwelling catheter. Which of the following measures should the nurse implement when performing hygiene care in regards to the indwelling catheter?
Cleanse the catheter from the meatus outward using mild soap and warm water.
Use the same cleansing cloth for cleaning of the perineal area and the catheter tubing.
Use chlorhexidine gluconate (CHG) to cleanse the perineal area
The Correct Answer is A
The correct answer is choice A. When performing hygiene care for a client with an indwelling catheter, the nurse should plan to cleanse the catheter from the meatus outward using mild soap and warm water. This helps to prevent infection and ensure proper hygiene. Using the same cleansing cloth for cleaning the perineal area and catheter tubing (choice B) is not recommended as it can cause contamination and increase the risk of infection. The use of chlorhexidine gluconate (CHG) to cleanse the perineal area (choice C) is not necessary for routine catheter care and should only be used for specific indications such as preventing infection during surgery. Therefore, the nurse should always follow proper hygiene protocols and cleanse the catheter from the meatus outward using mild soap and warm water when caring for a client with an indwelling catheter.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
The correct answer is choice B, safety measures necessary to prevent a fire. When teaching a home care client and their family about using prescribed oxygen, safety measures are critical. Oxygen supports combustion, so it is important to follow safety measures to prevent a fire. These safety measures include avoiding smoking, using electric razors instead of a blade, and avoiding flammable products such as oils, aerosol sprays, and alcohol-based hand sanitizers near the oxygen source. The oxygen should be kept away from heat sources and the tubing should be free from kinks or damage. The healthcare provider's phone number should also be readily available in case of any questions or emergencies.
Correct Answer is D
Explanation
The correct answer is choice D. Identify the five major drug side effects before discharge tomorrow. This is a measurable goal as it has a specific action, which is to identify five major drug side effects, and a specific time frame, which is before discharge tomorrow. The goal is also realistic and achievable within the given time frame. Option A, sitting out of bed in the chair, is not specific enough and lacks a time frame. Option B, verbalizing feelings about surgery at some point, is too vague and lacks a specific action and time frame. Option C, eating low-sodium food, is specific but lacks a time frame and may not be realistic given the client's condition.
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