A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include? (Select all that apply).

Measurement of residual urine after urination

An open perineal wound

Relief of urinary retention

Convenience for the nursing staff or the client's family

routine acquisition of a urine specimen

Answer and Explanation

Correct Answer : A,B,C

A.   Measurement of residual urine after urination is an indication of urinary catheterization because it can help diagnose conditions such as neurogenic bladder, bladder outlet obstruction, or urinary retention.
B.   An open perineal wound is an indication for urinary catheterization because it can prevent contamination of the wound by urine and facilitate wound healing.
C.   Relief of urinary retention is an indication of urinary catheterization because it can prevent complications such as bladder distension, infection, or renal damage.
D.   Convenience for the nursing staff or the client's family is not an indication of urinary catheterization because it can increase the risk of catheter-associated urinary tract infection (CAUTI), trauma, or encrustation.
E.   routine acquisition of a urine specimen is not an indication for urinary catheterization because it can be obtained by other methods such as clean catch, midstream, or suprapubic aspiration.

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Correct Answer is D

Explanation

A) The dorsal surface of the foot is not the most reliable site to assess for cyanosis in individuals with dark skin because the skin pigmentation can mask the bluish tint that indicates reduced oxygenation.
B) Similarly, the dorsal surface of the hand may not clearly show cyanosis due to the thickness and pigmentation of the skin, which can obscure the color change.
C) The pinnae of the ears may also not be the best indicator of cyanosis in dark-skinned individuals because peripheral areas like the ears can be affected by environmental temperatures, leading to misleading color changes.
D) The conjunctivae, however, are a mucous membrane where the skin pigmentation does not affect visibility. Therefore, it is an appropriate site for assessing cyanosis as it allows for the observation of subtle changes in color that indicate hypoxia. This is why the conjunctivae are the correct site to examine for cyanosis in a client with dark skin.

A. Providing oral care B. Emptying urine from an indwelling urine collection bag C. Placing oral medication tablets into a client's hand D. Delivering a food tray to a client who has AIDS E. Changing an ostomy pouch

Correct Answer is ["A","B","E"]

Explanation

A. Providing oral care involves contact with mucous membranes and saliva, which may contain blood or other potentially infectious materials. Therefore, the nurse should wear gloves to protect themselves and the client from cross-contamination.
B. Emptying urine from an indwelling urine collection bag involves contact with urine, which may contain blood or other potentially infectious materials. Therefore, the nurse should wear gloves to protect themselves and the client from cross-contamination.
C. Placing oral medication tablets into a client's hand does not involve contact with blood or other potentially infectious materials. Therefore, the nurse does not need to wear
gloves for this task.
D. Delivering a food tray to a client who has AIDS does not involve contact with blood or other potentially infectious materials. Therefore, the nurse does not need to wear gloves for this task. However, the nurse should follow standard precautions and wash their hands before and after contact with any client.
E. Changing an ostomy pouch involves contact with feces, which may contain blood or other potentially infectious materials. Therefore, the nurse should wear gloves to protect themselves and the client from cross-contamination.

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A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include? (Select all that apply).

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Naxlex Comprehensive Predictor Exams

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Correct Answer is D

Explanation

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following situations requires that the nurse wear gloves? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

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