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 B
Explanation
A. H2RAs are not typically associated with causing or alleviating diarrhea. Their primary function is to reduce gastric acid secretion, which is not directly related to diarrhea. Therefore, cessation of diarrhea is not an indicator of the therapeutic effect of an H2RA.
B. Heartburn is a common symptom associated with excess stomach acid, often due to conditions like GERD. H2RAs work by decreasing the amount of acid produced in the stomach, which helps relieve heartburn. Therefore, relief of heartburn is a direct indication that the H2RA is achieving its therapeutic effect.
C. Constipation is not a common effect of H2RAs; instead, it is often more related to other types of medications or dietary issues. Since H2RAs are designed to reduce stomach acid and not to affect bowel movements, the absence of constipation is not a relevant outcome for assessing the effectiveness of an H2RA.
D. Flatus, or gas, is not directly affected by H2RAs. The primary purpose of H2RAs is to manage acid- related conditions, and while gastrointestinal symptoms might be related, passage of flatus is not a specific indicator of the effectiveness of an H2RA.
Correct Answer is B
Explanation
A. While iron is crucial for overall health, its primary role in infants is not specifically related to vision development. Iron is essential for many bodily functions, including oxygen transport and brain development, but the statement about vision development is not directly relevant to the primary reasons for iron supplementation in infants.
B. This is a key point to include in the teaching. Iron stores that infants are born with start to deplete around 4-6 months of age. This is why iron-fortified formula or iron-rich complementary foods are recommended to prevent iron deficiency anemia, as breast milk alone may not provide sufficient iron after this period.
C. Iron is important for overall growth and development, including the development of red blood cells and cognitive functions. However, the specific facilitation of bone growth is more directly related to other nutrients like calcium and vitamin D.
D. Iron absorption can be a concern, but this statement is not entirely accurate. Iron in formula is typically well-absorbed, especially in iron-fortified formulas designed for infants. The goal of providing iron-fortified formula is to ensure that the infant receives an adequate amount of iron, which is absorbed effectively to support their growing needs.
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