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 A
Explanation
Rationale:
A. Clients will have a decreased incidence of foot amputations is a measurable outcome goal for a diabetes management program and aligns with long-term objectives of improving patient outcomes.
B. A facility will be reserved for the program is a logistical consideration but not a goal of the program itself.
C. Handouts and teaching materials will be distributed at the program is a part of the program's implementation, not a goal.
D. Proper foot care will be demonstrated to clients during the program is a teaching activity, not a program outcome goal.
Correct Answer is B
Explanation
Rationale:
A. “There are no provider's prescriptions available.” This reflects the Situation (current problem), not background.
B. The B (Background) step of SBAR includes relevant clinical history and context that led to the current situation. Explaining how the client was found provides important background information that helps the provider understand the circumstances surrounding the client’s condition.
C. “The client should be seen by a neurologist.” This is part of the Recommendation step, where the nurse suggests actions or next steps.
D. “The client is disoriented. Pupils are slow to respond to light.” This belongs in the Assessment step, as it describes the nurse’s clinical findings.
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