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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Discussing the LPN's behavior with other nurses could potentially lead to gossip and does not address the core issue.
B. The charge nurse does not have authority to review personnel files; this is handled by management or HR.
C.The most appropriate first step is to investigate the client concerns directly. This provides objective information to determine if further action (coaching, reassignment, reporting to management) is necessary.
D. Reassigning client care to assistive personnel does not address the root cause of the problem and may not be an appropriate or effective solution without further investigation.
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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