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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Iron supplements Iron supplements are commonly used to treat or prevent iron deficiency anemia. While beneficial in relieving iron deficiency, iron pills can cause side effects like constipation, diarrhea, nausea, vomiting, dark stools, stomach cramps, and a metallic taste. However, constipation is not the primary side effect of iron supplements.
Choice B rationale:
Magnesium-containing antacids Magnesium-containing antacids are used to relieve the symptoms of gastroesophageal reflux disease (GERD), heartburn, or indigestion. By neutralizing stomach acid, antacids relieve symptoms such as burning behind the breast bone or throat area caused by acid reflux, a bitter taste in the mouth, a persistent dry cough, pain when lying down, or regurgitation. While these antacids can cause diarrhea, they do not typically lead to constipation.
Choice C rationale:
Anticholinergics/Antispasmodics Anticholinergics and antispasmodics are used to relieve cramps or spasms of the stomach, intestines, and bladder. Some are used together with antacids or other medicines in the treatment of peptic ulcers. Others are used to prevent nausea, vomiting, and motion sickness. While these medications can cause a variety of side effects, constipation is not a primary side effect.
Choice D rationale:
Opioid narcotics Opioids, also known as narcotics, are a class of drugs healthcare providers prescribe to manage moderate to severe pain, as well as chronic coughing and diarrhea. Common side effects of narcotics include constipation, decreased sweating, dizziness, dry mouth, nose, throat, or skin. Therefore, opioid narcotics are the medication most likely to lead to constipation among the options provided.
Correct Answer is B
Explanation
Choice A rationale:
Taking the patient to the bathroom every 2 hours while the patient is awake is not the most effective strategy for a bowel training program. This approach does not take into account the natural rhythms of the body and the patient’s personal comfort. It may lead to unnecessary trips to the bathroom, which can be physically and emotionally draining for the patient.
Choice B rationale:
This is the correct answer. A bowel training program aims to help the patient regain control over their bowel movements. Taking the patient to the bathroom when they have the urge to defecate aligns with this goal. It allows the patient to respond to their body’s signals, which can help improve their confidence and independence over time.
Choice C rationale:
Taking the patient to the bathroom immediately before meals is not the most effective strategy for a bowel training program. While it’s true that eating can stimulate bowel movements due to the gastrocolic reflex, this approach does not consider the patient’s comfort or individual needs. It may also disrupt the patient’s enjoyment of their meals.
Choice D rationale:
Waiting until the patient feels abdominal cramping is not the most effective strategy for a bowel training program. Abdominal cramping can be a sign of constipation or other digestive issues. It’s important to address these issues separately and not rely on them as indicators for when to take the patient to the bathroom.
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