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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This vitamin is essential for wound healing. It plays a critical role in cellular immune responses, skin integrity, and the repair of epithelial tissues. Vitamin A helps in the formation of new skin cells and promotes collagen synthesis, which is vital for wound healing.
B. While vitamin D is crucial for bone health and calcium absorption, its direct role in wound healing is less pronounced compared to other nutrients. Vitamin D supports overall immune function, which can indirectly support the healing process, but it is not as directly involved in wound repair as vitamin A or other specific nutrients.
C. Vitamin B1 is important for carbohydrate metabolism and nerve function, but its direct role in wound healing is minimal compared to other vitamins. While essential for overall health, vitamin B1 does not specifically target wound healing processes.
D. Calcium is crucial for bone health and muscle function. It plays a role in blood clotting and can support overall health, but its direct impact on wound healing is less significant compared to nutrients like vitamin A and vitamin C.
Correct Answer is D
Explanation
A. Waist circumference alone is not a direct measure of overweight or obesity but can be an indicator of abdominal fat, which is a risk factor for health issues. For males, a waist circumference greater than 102 cm (40 in) is generally considered an increased risk for health problems related to obesity.
B. Body Mass Index (BMI) is a commonly used measure to classify weight status. For adults, a BMI of 24 falls within the "normal weight" range, which is between 18.5 and 24.9. This client is not classified as overweight, as the threshold for overweight is a BMI of 25 or higher.
C. For females, a waist circumference greater than 88 cm (35 in) is often considered an increased risk for health issues related to obesity. At 40 inches (101.6 cm), this female client exceeds the threshold and may be at higher risk for obesity-related health problems, though this does not strictly classify her as overweight based on BMI or waist circumference alone.
D. A BMI of 29 falls into the "overweight" category, which ranges from 25 to 29.9. Therefore, this male client is classified as overweight based on his BMI.
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