A nurse is planning care for a client who was admitted to the unit for pneumonia.
The nurse is planning care for the client.
Complete the following sentence by using the lists of options.
After providing perineal care and donning sterile gloves, the nurse should first
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
After providing perineal care and donning sterile gloves, the nurse should first lubricate the catheter tip followed by insert the catheter until urine flows.
Rationale:
- Lubricating the catheter tip ensures smooth insertion and minimizes discomfort or trauma to the urethra.
- Inserting the catheter until urine flows confirms proper placement before advancing slightly more to ensure complete drainage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
A. Positive Trousseau's sign: A positive Trousseau’s sign (carpal spasm induced by inflating a blood pressure cuff) is a classic indicator of hypocalcemia due to increased neuromuscular excitability.
B. Muscle cramps: Hypocalcemia leads to increased nerve excitability, causing muscle cramps, spasms, and tetany.
C. Tingling sensation around the lips: This is a common early sign of hypocalcemia, known as perioral paresthesia, due to increased nerve excitability.
D. Negative Chvostek's sign: A client with hypocalcemia would have a positive Chvostek’s sign, which is facial twitching when the facial nerve is tapped.
E. Abdominal distention: Hypocalcemia is more associated with diarrhea and hyperactive bowel sounds, not abdominal distention, which is more typical of hypokalemia.
Correct Answer is C
Explanation
A. Grasps the catheter 10.16 to 12.7 cm (4 to 5 in) from the tip The catheter should be held at least 5 to 7.6 cm (2 to 3 inches) from the tip to maintain better control and prevent contamination.
B. Cleanses the meatus using a clean cotton ball Aseptic technique requires a separate antiseptic swab or cotton ball for each stroke to avoid introducing bacteria.
C. Cleanses the meatus from the center in a circular motion Cleaning from the center outward prevents introducing bacteria into the urethra, which is essential for infection prevention.
D. Applies clean gloves before beginning the procedure Sterile gloves, not clean gloves, must be used during catheterization to maintain aseptic technique.
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