A nurse is caring for a female client who has a prescription for an indwelling urinary catheter. Which of the following actions should the nurse take first?
Clean the perineum from front to back.
Lubricate the catheter.
Explain to the client that she will feel temporary discomfort.
Arrange the sterile items on the sterile field.
The Correct Answer is D
A. Clean the perineum from front to back.
After arranging the sterile items, the next step involves preparing the client for catheter insertion, which includes cleaning the perineum from front to back using appropriate techniques to minimize the risk of infection.
B. Lubricate the catheter.
Following the preparation of the client, the next step involves lubricating the catheter before insertion. Lubrication facilitates the smooth and atraumatic insertion of the catheter.
C. Explain to the client that she will feel temporary discomfort.
Providing information and preparing the client for the procedure is an important aspect, but it typically follows the physical preparation steps. Explaining to the client about potential discomfort should be done before the procedure but after the necessary physical preparations are complete.
D. Arrange the sterile items on the sterile field.
This is the first action to be taken. It involves preparing all the necessary sterile items on a sterile field, ensuring that everything needed for the catheter insertion procedure is organized and ready to maintain aseptic technique.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Provide an antiemetic.
While providing an antiemetic can help alleviate the client's nausea and vomiting, it is not the priority action. Assessment should come first to determine the underlying cause.
B. Make the client NPO.
Making the client NPO might be necessary if there is concern about bowel obstruction or other gastrointestinal issues, but this decision should be based on an initial assessment, such as auscultating bowel sounds.
C. Administer a stimulant laxative.
Administering a stimulant laxative is not appropriate at this stage without first assessing bowel sounds. It could potentially worsen the situation if there is a bowel obstruction.
D. Auscultate bowel sounds.
The priority in this situation is to assess for possible complications such as bowel obstruction or paralytic ileus, which can occur postoperatively and can be exacerbated by opioid use. Auscultating bowel sounds helps determine the presence of normal, hypoactive, or absent bowel sounds, guiding further management.
Correct Answer is B
Explanation
A. “I wish I didn’t have to attach the electrodes to my skin.”
This statement reflects a common sentiment. Attaching electrodes to the skin is part of using TENS, and it's a non-invasive procedure where electrodes are placed on the skin surface to deliver electrical impulses for pain relief.
B. “It’s unfortunate that I have to be in the hospital for this treatment.”
This statement indicates a need for further teaching. TENS is typically an outpatient treatment, and individuals can use TENS units at home after receiving appropriate instructions and training. It does not require being in the hospital.
C. “I’ll need to shave the hair off the skin where I place the electrodes.”
This statement is accurate. To ensure proper contact and effectiveness, it is often recommended to shave or trim the hair in the area where the electrodes will be placed.
D. “I hope I don’t have to take as many pain pills.”
This statement reflects an understanding of the potential benefits of TENS. TENS is used as an adjunct therapy to help manage pain, and one of its goals may be to reduce the need for pain medications.
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