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 ["C"]
Explanation
The correct answer is Choice C.
Choice A rationale: Applying four drops of developing solution to each stool specimen is incorrect. Typically, the test requires two drops of solution. Following manufacturer instructions ensures accurate results and prevents unnecessary waste or inaccurate readings.
Choice B rationale: Using toilet paper to transfer the stool specimen is improper. Stool should be collected using the provided applicator stick to avoid contamination, ensuring the accuracy of the fecal occult blood test.
Choice C rationale: Waiting 30 seconds after applying the developing solution allows the chemical reaction to complete, ensuring accurate detection of any occult blood present in the stool sample.
Choice D rationale: Collecting two stool specimens from the same area increases the risk of missing occult blood present in different parts of the stool. Sampling from multiple areas enhances test accuracy and ensures comprehensive results.
Correct Answer is ["D"]
Explanation
Choice A rationale:
Petroleum-based ointments like Vaseline are not recommended for moisturizing lips, especially for patients on oxygen therapy. This is because petroleum jelly is not effective at restoring moisture once it’s been lost. Moreover, it can feel heavy and slippery on the lips, and it’s not very eco-friendly.
Choice B rationale:
Oxygen tanks should be kept at a safe distance from heat sources, including electric stoves. However, the recommended distance is not 4 feet but rather at least 5-10 feet away. This is to minimize the risk of fire or combustion.
Choice C rationale:
Wool blankets are not recommended when using oxygen. Wool can cause a spark which can be dangerous around oxygen. It’s important to avoid anything that may cause a spark around home oxygen, including electric heaters, electric blankets, electric razors, hair dryers, or friction toys.
Choice D rationale:
Oxygen tanks should always be stored upright. This prevents any strain on the valves or other components and reduces the risk of damage and potential gas leaks.
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