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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. A client who has pneumonia and has an axillary temperature of 38° C (101° F) has an elevated temperature, but it is less critical than immediate concerns with circulation.
B. A client who has diarrhea and requests clear liquids for breakfast needs dietary adjustments but does not present as urgent.
C. A client who has a cast on the left leg and reports numbness and paresthesia could be experiencing complications such as compartment syndrome, which is an urgent condition requiring immediate assessment.
D. A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150 is important to monitor but not as immediately critical as potential complications with circulation.
Correct Answer is B
Explanation
Rationale:
A. Hospice care focuses on comfort and quality of life, not on curing the illness. Therefore, the oncologist would typically shift focus to palliative care.
B. Managing symptoms such as dyspnea is a primary aspect of hospice care, aimed at improving the quality of life.
C. Hospice care is usually for patients with a prognosis of six months or less, not for those with indefinite life expectancy.
D. Hospice care can be provided in various settings, including the patient’s home, not just long-term care facilities.
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