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","B","C","D"]
Explanation
A. This helps to remove dirt, pesticides, and harmful bacteria that may be present on the surface of the vegetables.
B. This ensures that any bacteria that may have grown on the food are killed.
C. Unpasteurized dairy products may contain harmful bacteria, such as Salmonella and Listeria.
D. This helps to prevent the growth of bacteria.
E. Cooked foods should be kept hot (above 60°C/140°F) or cold (below 4°C/40°F) to prevent bacterial growth.
Correct Answer is C
Explanation
A. The client may have difficulty voiding despite being taken to the bathroom, especially if there is an underlying issue such as urinary retention or an obstruction. Therefore, this step is usually taken after assessing the situation further.
B. Inserting a straight catheter is an invasive procedure that should not be the initial action. It is typically done after other non-invasive measures have been taken to evaluate the reason for the lack of voiding. Straight catheterization can be considered if other methods do not resolve the issue or if there is a clear indication of urinary retention that needs immediate intervention.
C. Performing a bladder scan is the appropriate first step. A bladder scan, or portable ultrasound, helps assess the amount of urine in the bladder and determines if the client is retaining urine. This non- invasive procedure can provide valuable information about the presence of urinary retention, which guides further intervention.
D. Increasing fluid intake might be appropriate if the client is dehydrated or has not been drinking enough fluids. However, this step is not the first action to take if the client has not voided for 8 hours. The priority is to determine if there is a physiological issue, such as urinary retention, before increasing fluids.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.