The nurse provides care to a toddler-age client and prescribed catheterization to obtain a urine specimen. Which procedure does the nurse implement? (Select all that apply)
Explain the procedure in detail before beginning
Have the child blow on a pinwheel during insertion
Insert the catheter about 5 cm
Use a size 10 Fr catheter
Insert 2% lidocaine lubricant into the meatus
Use firm pressure if resistance is met
Correct Answer : A,B,D,E
It is important to explain the procedure in detail before beginning to help the child understand what is happening and reduce anxiety. Having the child blow on a pinwheel during insertion can help distract them and reduce discomfort. A size 10 Fr catheter is appropriate for a toddler-age child ¹². Inserting 2% lidocaine lubricant into the meatus can help reduce discomfort during the procedure.
On the other hand, inserting the catheter about 5 cm may not be appropriate as the depth of insertion varies depending on the child's anatomy. Using firm pressure if resistance is met is not recommended as it can cause injury to the urethra.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is known as a clean-catch urine sample. The nurse cleanses the urinary meatus to reduce the chance of contamination from bacteria on the skin. The patient then collects a urine sample in a sterile container while voiding.

Correct Answer is ["B","C"]
Explanation
The client has a complication of the surgical wound dehiscence, which occurs when the wound edges separate or pull apart. In this case, a portion of the intestine is protruding from the wound bed, indicating a wound evisceration. It is a medical emergency that requires prompt intervention to prevent complications such as infection, hemorrhage, or sepsis.
The nurse should first stay with the client and call for assistance to notify the healthcare provider or surgical team immediately. The surgical team will need to evaluate the wound and perform emergency surgery if necessary.
The nurse should then place sterile moistened ABD pads over the wound to prevent the intestine from drying out and to protect the protruding tissue from further injury or infection.
Placing the client in Trendelenburg position (a) is contraindicated as it can cause a shift of abdominal contents and further worsen the condition. Attempting to reinsert the intestine into the abdominal cavity (d) is also not within the scope of practice for the nurse and can cause harm to the client. Encouraging the client to drink fluids (e) or obtaining the client's vital signs (f) are not the priority actions in this situation.

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