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.
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Related Questions
Correct Answer is B
Explanation
A. The client cannot change their mind after signing consent. Clients have the right to withdraw consent at any time before the procedure begins.
B. The alternative treatments to the procedure should be explained. Informed consent includes information about alternative treatments and their risks/benefits so the client can make an informed decision.
C. The time of the procedure should be indicated on the form. The time of the procedure is not a required component of informed consent. The consent form should include the procedure details, risks, benefits, and alternatives
D. The charge nurse should review the form once it's signed. While nurses witness informed consent, they do not validate or review it. The provider performing the procedure is responsible for obtaining consent.
Correct Answer is B
Explanation
A. "Place the head of the bed flat before using the incentive spirometer." The client should be in a semi-Fowler’s or high-Fowler’s position (sitting upright) to maximize lung expansion.
B. "Hold your breath for 2 to 3 seconds when using the incentive spirometer." Holding the breath allows for maximum lung expansion and helps prevent atelectasis (lung collapse).
C. "Use the incentive spirometer every 3 hours while awake." The incentive spirometer should be used every 1 to 2 hours while awake to promote lung expansion and prevent complications such as pneumonia.
D. "Breathe in through your nose when using the incentive spirometer." The client should inhale deeply through the mouth, not the nose, to ensure proper lung inflation.
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