A charge nurse is observing a nurse Insert an indwelling urinary catheter into a female client. For which of the following actions by the nurse should the charge nurse intervene?

The nurse coats the indwelling urinary catheter with lubricant.

The nurse applies the sterile drape prior to inserting the urinary catheter.

The nurse provides perineal care prior to inserting the urinary catheter.

The nurse separates the client's labia with her dominant hand.

Answer and Explanation

The Correct Answer is D

Rationale:

A. The nurse coats the indwelling urinary catheter with lubricant is correct and necessary for the procedure to reduce discomfort and facilitate insertion.

B. The nurse applies the sterile drape prior to inserting the urinary catheter is a proper step to maintain a sterile field during the procedure.

C. The nurse provides perineal care prior to inserting the urinary catheter is appropriate as it ensures cleanliness before catheter insertion.

D. The nurse separates the client's labia with her dominant hand should not be done; the non-dominant hand should be used to hold the labia apart to maintain sterility.

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Correct Answer is D

Explanation

Rationale:

A. Agency policies for the LPN are important but secondary to ensuring the tasks fall within the scope of practice.

B. The documented experience level of the LPN is relevant but should be considered in conjunction with the scope of practice.

C. The documented skill level of the LPN is important for assigning tasks but must align with legal scope of practice.

D. State Nurse Practice Act for the LPN is the priority criterion as it defines the legal scope of practice and ensures that tasks delegated to the LPN are within their legal and professional boundaries.

A. "I have my assignment and will start with room 1, then work my way to room 10." B. "After breakfast, I will pack the belongings of clients who will be discharged this morning." C. "I will start by providing partial baths before breakfast." D. "I will give this client his meal tray first, as he is going early to physical therapy."

Correct Answer is A

Explanation

Rationale:

A. Starting with room 1 and working to room 10 suggests a lack of prioritization based on client needs, which is important for efficient and effective care.

B. Packing belongings after breakfast is a reasonable plan, assuming it fits within the priorities of the shift.

C. Providing partial baths before breakfast might be acceptable depending on the client’s needs and the urgency of the task.

D. Giving a client their meal tray first based on their scheduled physical therapy is an example of prioritizing care based on client needs.

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A charge nurse is observing a nurse Insert an indwelling urinary catheter into a female client. For which of the following actions by the nurse should the charge nurse intervene?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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