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 B
Explanation
A. "I will rest for at least 30 minutes before eating."
This statement is appropriate. Resting before meals can help conserve energy and reduce dyspnea (shortness of breath) during eating for individuals with COPD.
B. "I will drink plenty of beverages with my meals."
This statement indicates a need for further teaching. Excessive fluid intake during meals can contribute to feelings of fullness and increase the risk of bloating, making it more difficult for the client with COPD to breathe comfortably.
C. "I will eat five or six small meals each day."
This statement is appropriate. Eating smaller, more frequent meals can help prevent overdistension of the stomach and reduce the feeling of fullness, making it easier for the client to breathe.
D. "I will increase my intake of protein."
This statement is appropriate. Adequate protein intake is important for individuals with COPD to support respiratory muscle function and overall nutritional status.
Correct Answer is C
Explanation
A. “I will keep my baby’s head slightly elevated during the feeding.”
This statement is correct. Keeping the baby's head slightly elevated during feeding can help prevent ear infections (otitis media) and is a recommended practice.
B. “I will hold my baby close to me while feeding.”
Holding the baby close during feeding promotes bonding and is generally considered a good practice for both bottle-feeding and breastfeeding.
C. “Each feeding should last about 15 minutes.”
This statement indicates a need for further teaching. The duration of a feeding can vary among infants, and it's not advisable to put a strict time limit on each feeding. It's important to follow the baby's cues and allow for individual variations in feeding patterns.
D. “Propping a bottle can cause otitis media.”
This statement is correct. Propping a bottle can lead to ear infections (otitis media) and is not a safe or recommended practice. The baby should be held during feedings to prevent these issues.
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