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 C

Explanation

Rationale:

A. Reporting the observation to the nurse caring for that client is important but not the immediate priority.

B. Informing the nursing supervisor is necessary but should be done after assessing the situation directly.

C. Approaching the man and asking why he is making copies is the most immediate and direct action. It allows the nurse to assess the situation and determine if the man has legitimate access to the client's medical record or if further action is needed.

D. Notifying hospital security may be necessary if the man’s actions are unauthorized, but the first step is to gather more information.

A. Assigning the most competent RN to perform a central line dressing change B. Assigning the most efficient AP to perform glucometer monitoring for each client C. Assigning two assistive personnel (AP) to ambulate all clients D. Assigning a new graduate nurse to perform a wet-to-dry dressing change

Correct Answer is D

Explanation

Rationale:

A. Assigning an RN to perform a central line dressing change is appropriate as it requires specialized skills and knowledge.

B. Assigning an AP to perform glucometer monitoring is within their scope of practice and is a suitable task.

C. Assigning two APs to ambulate clients is reasonable if the workload requires it.

D. Assigning a new graduate nurse to perform a wet-to-dry dressing change may be inappropriate if it requires more experience and skill than the new graduate has.

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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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