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 A

Explanation

Choice A rationale:

Circulatory overload, also known as hypervolemia or fluid overload, is a condition where the body has too much fluid. This excess fluid, especially in the circulatory system, can lead to a rapid heartbeat. This is because the heart needs to work harder to pump the increased volume of blood, leading to an increased heart rate.

Choice B rationale:

Weight loss is not typically associated with circulatory overload. In fact, quick weight gain might be observed due to the excess fluid in the body.

Choice C rationale:

Low blood pressure is not a common symptom of circulatory overload. On the contrary, high blood pressure can occur because the excess fluid in the circulatory system puts more pressure on the blood vessel walls.

Choice D rationale:

Excessive sweating is not a direct symptom of circulatory overload. However, symptoms such as shortness of breath and swelling in certain areas of the body are more common.

A. Wheezing B. Flank pain C. Elevated blood pressure D. Distended neck veins E. Answer and explanation The

Correct Answer is A

Explanation

Choice A rationale:

Wheezing is a common symptom of an allergic transfusion reaction. An allergic transfusion reaction occurs when the recipient’s immune system reacts to foreign proteins or allergens in the donor’s blood. Symptoms of an allergic reaction can range from mild to severe, and they typically include skin reactions such as hives and itching, as well as respiratory symptoms like wheezing. In severe cases, the reaction can cause difficulty breathing.

Choice B rationale:

Flank pain is not typically associated with an allergic transfusion reaction. It is more commonly a symptom of conditions affecting the kidneys or urinary tract. While flank pain can occur in a hemolytic transfusion reaction due to the rapid destruction of red blood cells, it is not a symptom of an allergic reaction.

Choice C rationale:

Elevated blood pressure is not a typical symptom of an allergic transfusion reaction. Allergic reactions more commonly cause symptoms such as hives, itching, and respiratory symptoms like wheezing. In severe cases, an allergic reaction can actually lead to a drop in blood pressure.

Choice D rationale:

Distended neck veins are not a typical symptom of an allergic transfusion reaction. They are more commonly associated with conditions that cause increased pressure in the right side of the heart. While distended neck veins can occur in a transfusion reaction due to fluid overload, they are not a symptom of an allergic reaction.

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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?

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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?