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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Use a blow dryer on a moderate heat setting to dry the cast after showering.

This is not recommended as using a blow dryer on a cast can cause burns. Instead, the cast should be allowed to air-dry or be dried with a fan.

B. Use a cotton swab to relieve itching under the cast.

Inserting objects, including cotton swabs, under the cast can lead to complications such as infection or skin damage. It is not recommended to insert anything into the cast.

C. Report any worsening or unrelieved pain.

This is the correct instruction. Persistent or increasing pain can indicate complications such as swelling, infection, or neurovascular compromise. It is important for the client to promptly report any changes in pain to healthcare providers.

D. Avoid moving the affected leg.

While it's important to limit movement to allow for proper healing, complete immobilization can lead to joint stiffness and muscle atrophy. Gentle range-of-motion exercises for non-weight-bearing areas may be encouraged, but any specific movement instructions should be provided by the healthcare provider. If movement causes significant pain or discomfort, the client should consult the healthcare provider.

A. Assign an assistive personnel to feed the client. B. Explain that the tray is here and place the client’s hands on the tray. C. Describe to the client the location of the food on the tray. D. Ask the client if she would prefer a liquid diet.

Correct Answer is C

Explanation

A. Assign an assistive personnel to feed the client.

This option involves assigning someone else to feed the client. While it may ensure that the client receives adequate nutrition, it does not promote independence. The client may prefer to feed themselves if given the opportunity.

B. Explain that the tray is here and place the client’s hands on the tray.

While explaining the presence of the tray is helpful, physically placing the client's hands on the tray is a more direct form of assistance. It takes away the opportunity for the client to explore and locate items independently.

C. Describe to the client the location of the food on the tray.

This is the correct choice. Describing the location of the food on the tray allows the client to use their remaining senses, such as touch and hearing, to independently locate and eat their food.

D. Ask the client if she would prefer a liquid diet.

This option is related to dietary preferences but does not directly address the issue of promoting independence in eating. It focuses more on the type of diet rather than the manner in which the client can independently manage their meals.

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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?

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