The student nurses ask the RN if a Foley catheter would be an appropriate intervention to protect intact skin for a patient who is not ambulatory, incontinent, and confused.
The nurse knows that it would be appropriate to ask the physician for an order to place a Foley catheter for this patient.
True.
False.
The Correct Answer is A
Choice A rationale
Using a Foley catheter can help prevent skin breakdown caused by prolonged contact with urine in incontinent patients, especially if they are confused or non-ambulatory and unable to use other urinary devices. Maintaining intact skin is crucial to avoiding infections and pressure injuries, making a Foley catheter a suitable intervention in specific cases when prescribed.
Choice B rationale
Foley catheters are not inherently inappropriate but must be prescribed judiciously due to risks like urinary tract infections. While alternative methods may be preferable, this intervention is justified for incontinent, immobile patients with compromised mental status to protect skin integrity. It aligns with clinical guidelines and patient-specific needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is F
Explanation
Choice A rationale
Dextrose IVP is unnecessary with hyperglycemia. It increases the glucose level further, risking complications like hyperosmolar hyperglycemic state. This treatment is reserved for severe hypoglycemia.
Choice B rationale
Glucagon raises blood glucose and is contraindicated for hyperglycemia. It is used to treat hypoglycemia, not elevated glucose levels seen here.
Choice C rationale
Holding insulin neglects hyperglycemia management, allowing complications like ketoacidosis or delayed glucose control. Insulin is necessary to address elevated blood sugar.
Choice D rationale
Calling the MD delays hyperglycemia treatment unnecessarily, as nurses can administer insulin per protocols in cases like this.
Choice E rationale
Administering 15 units of Humalog risks inducing hypoglycemia. It is an excessive dose given the glucose level of 243 mg/dL.
Choice F rationale
Administering 4 units of Humalog is an appropriate corrective dose for a pre-meal glucose of 243 mg/dL. Rapid-acting insulin efficiently reduces glucose to safer levels, aligning with treatment protocols.
Choice G rationale
Administering 9 units of Humalog risks overcorrecting hyperglycemia, potentially causing hypoglycemia, as it exceeds typical sliding scale guidelines for this glucose level.
Choice H rationale
Administering 5 units of Humalog could be reasonable for slight hyperglycemia, but it is not specifically aligned with the sliding scale dose appropriate for 243 mg/dL.
Correct Answer is A
Explanation
Choice A rationale
Contact isolation prevents the transmission of Clostridium difficile spores, a significant source of nosocomial infections. Private rooms reduce cross-contamination risks.
Choice B rationale
Antidiarrheal use is contraindicated in Clostridium difficile infection as it may worsen colitis by retaining toxins. Prompt stool elimination is vital.
Choice C rationale
Antibiotics are used to treat Clostridium difficile but educating the patient about antibiotic cessation is inappropriate as their use is essential for infection control.
Choice D rationale
Stool softeners are unnecessary since diarrhea is already present, and further softening may exacerbate fluid and electrolyte loss.
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