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 B
Explanation
Choice A rationale:
Administering insulin is a crucial step in managing diabetic ketoacidosis (DKA), as insulin deficiency is a primary cause of DKA12. However, it is not the first action to take when a patient presents with both DKA and hypoxia. While insulin helps to reduce blood glucose levels and suppress the production of ketones, it does not address the immediate life-threatening condition of hypoxia.
Choice B rationale:
Hypoxia, or low levels of oxygen in the body, is a medical emergency that requires immediate attention. Supplemental oxygen can help increase the oxygen levels in the patient’s blood, thereby alleviating hypoxia. In the context of a patient with DKA and hypoxia, providing supplemental oxygen would be the first action to take to stabilize the patient’s condition before addressing the DKA12.
Choice C rationale:
Checking the patient’s glucose level is an important part of managing DKA, as hyperglycemia is a key feature of this condition. However, it is not the first action to take in this scenario. While monitoring glucose levels can guide the administration of insulin and other treatments for DKA, it does not address the immediate threat posed by hypoxia.
Choice D rationale:
Administering intravenous fluids is another important step in managing DKA12. Dehydration is a common complication of DKA due to excessive urination caused by high blood sugar levels. However, similar to Choices A and C, while it is an important part of treatment, it is not the first action to take when a patient presents with both DKA and hypoxia.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.