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 A

Explanation

A. Discuss a referral to home health and hospice care with the client and family.

This is the correct answer. Discussing a referral to home health and hospice care addresses the client's expressed desire to go home and provides the necessary support and care for both the client and the family during this challenging time.

B. Contact the social worker to assist with nursing home placement.

This option may not align with the client's wish to go home. Nursing home placement may not be the preferred choice, especially when the client wants to spend their final days in a home setting.

C. Talk with the provider about extending the client’s hospital stay.

Prolonging the hospital stay may not meet the client's expressed wish to go home and may not provide the same level of comfort and support as home health and hospice care.

D. Instruct the family about meeting the client’s palliative care needs at home.

While providing information about meeting palliative care needs at home is important, it is more comprehensive to involve home health and hospice services, which can provide skilled care, emotional support, and assistance to the family in managing the client's care needs at home.

A. “You should avoid the use of cell phones after the pacemaker is placed.” B. “Swelling and redness of the operative site are normal findings for the first two days following the procedure.” C. “You will need to limit movement of the arm on the side of the pacemaker.” D. “Hiccups following pacemaker placement are an expected response.”

Correct Answer is C

Explanation

A. “You should avoid the use of cell phones after the pacemaker is placed.”

This statement is not accurate. In general, the use of cell phones is considered safe for individuals with pacemakers. However, it is recommended to keep the phone on the opposite side of the pacemaker to minimize any potential interference.

B. “Swelling and redness of the operative site are normal findings for the first two days following the

procedure.”

This statement is partially accurate. Swelling and redness at the operative site can be expected immediately after the procedure. However, if these signs persist or worsen after the first two days, it may indicate a potential issue, and the healthcare provider should be notified.

C. “You will need to limit movement of the arm on the side of the pacemaker.”

This statement is accurate. Limiting movement of the arm on the side of the pacemaker is a standard precaution to prevent dislodgement of the leads and allow proper embedding of the pacemaker leads into the surrounding tissues.

D. “Hiccups following pacemaker placement are an expected response.”

This statement is not accurate. Hiccups are not typically associated with pacemaker placement. If the client experiences unexpected symptoms, such as hiccups, it is important to report them to the healthcare provider for further evaluation.

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