A nurse is inserting an indwelling urinary catheter for a female client.
In which order should the nurse perform the following steps? (Move the steps
into the box on the right, placing them in the order of performance.
Use all the steps.).

Separate the labia with the nondominant hand.

Clean around the urinary meatus from front to back.

Insert the catheter into the urethral meatus.

Inflate the catheter balloon.

Secure the catheter to the client’s thigh.

Answer and Explanation

Correct Answer : A,B,C,D,E

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Correct Answer is A

Explanation

This is because a frayed electrical cord can pose a serious risk of electric shock or fire to the client and the nurse.

The nurse should act quickly to eliminate the hazard and ensure the safety of the client and others.

Choice B is wrong because accessing the facility’s maintenance protocol is not the first action the nurse should take.

The nurse should prioritize removing the device from the room before following any protocol.

Choice C is wrong because reporting defective equipment is not the first action the nurse should take.

The nurse should prioritize removing the device from the room before reporting it to the appropriate authority.

Choice D is wrong because requesting a replacement device is not the first action the nurse should take.

The nurse should prioritize removing the device from the room before requesting a new one.

A. Elevate the client’s feet with two pillows. B. Raise the head of the client’s bed to a 30° angle. C. Raise the head of the client’s bed to a 60° angle. D. Place a pillow under the client’s flexed leg.

Correct Answer is D

Explanation

The correct answer is choice D. Placing a pillow under the client’s flexed leg is part of the Sims’ position, which is a way of lying on the left side, with the right hip and knee bent and the left arm behind the back.

It is used for vaginal and colonic examinations and natural childbirth.

Choice A is wrong because positioning the client’s arms at his sides is not part of the Sims’ position.

The left arm should be behind the back.

Choice B is wrong because elevating the client’s feet with two pillows is not part of the Sims’ position.

The lower leg should be straightened and the upper leg should be bent.

Choice C is wrong because raising the head of the client’s bed to a 30° angle is not part of the Sims’ position.

The bed should be flat or slightly tilted.

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A nurse is inserting an indwelling urinary catheter for a female client. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While performing hygiene care for a client, a nurse notices a frayed electrical cord on the client’s electronic blood pressure monitor. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is planning to place a client into the Sims’ position. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

A nurse is caring for a client who was recently admitted to hospice care and tells the nurse, “I am going to die and my family is hoping for a cure. I am mad that they behave like everything will be fine.” Which of the following responses should the nurse make?

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A nurse is caring for a group of clients. For which of the following situations should the nurse complete an incident report? (Select all that apply.).

A nurse is collecting data about a client’s oral care. The client wears dentures and reports having mouth sores. The nurse should identify which of the following oral care practices by the client as a possible cause of the mouth sores?

A nurse is assisting a client who is 4 hr postoperative to get out of bed. The client states, “Do not touch me! I can get up by myself.” Which of the following responses should the nurse make?

A nurse is showing a newly licensed nurse how to use a mechanical lift. Which of the following statements by the newly licensed nurse indicates an understanding of this assistive device?

A nurse is inserting an indwelling urinary catheter for a female client.
In which order should the nurse perform the following steps? (Move the steps
into the box on the right, placing them in the order of performance.
Use all the steps.).