A charge nurse is observing a newly-licensed nurse insert an Indwelling urinary catheter for a male client. Which of the following actions by the newly-licensed nurse requires intervention by the charge nurse?
Lubricates the first 2.5 to 5 cm (2 in) of the catheter.
Dons sterile gloves before cleaning the client's meatus.
Secures the tubing to the client's upper thigh.
Pulls gently on the catheter to check for resistance after inflating the balloon.
The Correct Answer is C
A. Lubricating the catheter helps reduce friction and discomfort during insertion.
B. Sterile gloves help prevent the introduction of microorganisms into the urinary tract.
C. Securing the tubing to the client's upper thigh can lead to discomfort and increased risk of skin irritation. The tubing should be secured to the client's lower abdomen or inner thigh to prevent tension and potential complications.
D. Gently pulling on the catheter after inflating the balloon helps ensure that the balloon is fully inflated and properly positioned in the bladder.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Anxiety disorders are commonly associated with eating disorders. Individuals with eating disorders may experience excessive worry, fear, or panic, which can contribute to their disordered eating behaviors.
B. While sleep disturbances are common in individuals with eating disorders, breathing-related sleep disorders are not typically associated with them.
C. Schizophrenia is a severe mental illness characterized by delusions, hallucinations, and disorganized thinking. It is not typically associated with eating disorders.
D. OCD is often comorbid with eating disorders. Individuals with OCD may have obsessive thoughts about food, weight, or body image, leading to compulsive behaviors such as excessive exercise or restrictive eating.
E. Depression is one of the most common comorbidities associated with eating disorders. Individuals with eating disorders may experience feelings of sadness, hopelessness, and worthlessness, which can contribute to their disordered eating behaviors.
Correct Answer is A
Explanation
A. A urine output of 175 mL over 8 hours is significantly below normal, which is generally considered less than 0.5 mL/kg/hr in adults (the normal range is about 0.5-1.5 mL/kg/hr). Reduced urine output can be indicative of acute kidney injury or worsening renal function, and it needs prompt evaluation and intervention.
B. This finding is generally not urgent but could be noted. Strong-smelling urine, especially in the morning, may be due to concentration of waste products overnight or dietary factors. While it might suggest dehydration or infection, it is less immediately concerning than changes in urine output. If accompanied by other symptoms such as pain, fever, or changes in urine color, it might warrant further investigation.
C. This finding is typically within normal limits and may not need immediate reporting. Normal urine output is about 800-2,000 mL per day. An output of 2,200 mL is slightly elevated but still within the normal range, depending on fluid intake.
D. This finding is generally not urgent but worth noting. Cloudy urine can result from the presence of cells, bacteria, or other substances. It may become cloudy after standing due to the formation of crystals or precipitation of substances.
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