A charge nurse in a long-term care facility is observing another nurse who is inserting an indwelling urinary catheter into a female patient.
Which action by the nurse should prompt the charge nurse to intervene?

The nurse applies the sterile drape after cleaning the perineal area.

The nurse lubricates the indwelling urinary catheter.

The nurse separates the patient’s labia with her dominant hand.

The nurse provides perineal care prior to inserting the urinary catheter.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C.

Choice A rationale:

The nurse applies the sterile drape after cleaning the perineal area. This is correct because the perineal area should be cleaned before applying the sterile drape. Applying the drape first could potentially introduce bacteria to the catheter during insertion, increasing the risk of a urinary tract infection.

Choice B rationale:

The nurse lubricates the indwelling urinary catheter. This is a correct procedure as it helps to minimize discomfort and trauma during catheter insertion.

Choice C rationale:

The nurse separates the patient’s labia with her dominant hand. This is also a correct procedure. The nurse should use her non-dominant hand to separate the labia and expose the urethral meatus, and then use her dominant hand to insert the catheter.

Choice D rationale:

The nurse provides perineal care prior to inserting the urinary catheter. This is a correct procedure. Providing perineal care before inserting a urinary catheter is important to reduce the risk of introducing bacteria into the urinary tract. It’s part of maintaining strict aseptic technique during insertion.

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Correct Answer is C

Explanation

Choice A rationale:

Hypothermia, or abnormally low body temperature, is not typically a symptom of diarrhea. While it’s possible for a person with severe diarrhea to experience chills or feel cold, hypothermia is not a direct result of diarrhea.

Choice B rationale:

A rigid abdomen is often a sign of a serious condition like peritonitis (inflammation of the peritoneum, the tissue that lines the inner wall of the abdomen), but it is not typically associated with diarrhea.

Choice C rationale:

Dehydration is a common complication of diarrhea. When a person has diarrhea, they can lose a lot of fluid and electrolytes quickly, leading to dehydration. Symptoms of dehydration can include thirst, less frequent urination, dark-colored urine, fatigue, dizziness, and confusion.

Choice D rationale:

Decreased bowel sounds are not typically associated with diarrhea. In fact, bowel sounds may actually increase in some cases of diarrhea due to increased gut motility.

A. Metabolic alkalosis B. Respiratory acidosis C. Respiratory alkalosis D. Metabolic Acidosis

Correct Answer is B

Explanation

Choice A rationale:

Metabolic alkalosis Metabolic alkalosis is a condition that occurs when your body has too many bases. It can occur due to prolonged vomiting, use of diuretics, or an overuse of antacids. In the context of Chronic Obstructive Pulmonary Disease (COPD), metabolic alkalosis is not typically a direct result of the disease. COPD primarily affects the respiratory system and does not directly cause an imbalance of bases in the body.

Choice B rationale:

Respiratory acidosis Respiratory acidosis is a condition that occurs when the lungs can’t remove enough carbon dioxide (CO2). This leads to a buildup of CO2 in the body, causing the pH of the blood to decrease and become more acidic. This is the most common acid-base imbalance seen in patients with COPD1. COPD can cause an alteration in respiratory exchanges, leading to retention of CO21. The consequence of hypercapnia due to alteration of gas exchange in COPD patients mainly consists in an increase of H+ concentration and development of respiratory acidosis.

Respiratory alkalosis Respiratory alkalosis is a condition that occurs when there is too little carbon dioxide in the body, often due to hyperventilation. In the context of COPD, this is less likely because COPD patients often have difficulty expelling carbon dioxide, not an excess of it being expelled.

Choice D rationale:

Metabolic Acidosis Metabolic acidosis occurs when the body produces too much acid, or when the kidneys are not removing enough acid from the body. This can occur due to conditions such as kidney disease, lactic acidosis, or ketoacidosis. While COPD can have wide-ranging effects on the body, it does not typically cause metabolic acidosis directly.

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A charge nurse in a long-term care facility is observing another nurse who is inserting an indwelling urinary catheter into a female patient. Which action by the nurse should prompt the charge nurse to intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is gathering information from a patient who has been experiencing diarrhea for several days. What symptoms should the nurse anticipate?

Correct Answer is C

Explanation

A nurse is caring for a client who has Chronic Obstructive Pulmonary Disease (COPD). Which of the following acidbase imbalances is the client at risk for?

Correct Answer is B

Explanation

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A charge nurse in a long-term care facility is observing another nurse who is inserting an indwelling urinary catheter into a female patient. Which action by the nurse should prompt the charge nurse to intervene?

A nurse is providing dietary advice to a patient at risk for hypokalemia. Which food should the nurse recommend as a good source of potassium?

A charge nurse in a long-term care facility is observing another nurse who is inserting an indwelling urinary catheter into a female patient.
Which action by the nurse should prompt the charge nurse to intervene?