A nurse is planning to perform intermittent urinary catheterization for a client who is unable to urinate. Which of the following actions should the nurse take first?
Perform a bladder scan.
Cleanse the meatus.
Provide perineal care.
Lubricate the catheter.
The Correct Answer is A
The correct answer is choice A. Perform a bladder scan.
Choice A rationale:
Performing a bladder scan is the first action the nurse should take before proceeding with intermittent urinary catheterization. A bladder scan assesses the bladder's volume and determines if catheterization is necessary. It helps avoid unnecessary catheterizations, reduces the risk of infection, and promotes patient comfort.
Choice B rationale:
While cleansing the meatus and providing perineal care are important steps in preparing for urinary catheterization, they come after assessing the need for catheterization. Without knowing the bladder volume, these actions could be premature.
Choice C rationale:
Providing perineal care is important for maintaining hygiene and preventing infection, but it should be done after the decision for catheterization has been made based on the bladder scan results.
Choice D rationale:
Lubricating the catheter is a step that should be taken after the decision for catheterization is made and the need for catheterization is confirmed. It helps ease the insertion process and reduce discomfort for the patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choiceC. “You should cleanse your eye from the inner to the outer edge prior to putting in the drops.”
Choice A rationale:
Looking to the side when putting in eye drops is not recommended.The correct technique involves looking up to help the drop fall into the eye more easily.
Choice B rationale:
Putting drops directly in the center of the eyeball can cause discomfort and may not be effective.The drops should be placed in the lower eyelid pocket.
Choice C rationale:
Cleansing the eye from the inner to the outer edge helps remove any debris or discharge, reducing the risk of infection and ensuring the drops are effective.
Choice D rationale:
Pressing on the tear duct after putting in eye drops can help prevent the medication from draining away too quickly, ensuring better absorption.
Correct Answer is C
Explanation
The correct answer is Choice C: Take vitamin D supplements.
Choice A rationale:
Reducing intake of calcium-rich foods would not be a suitable recommendation. Calcium is essential for bone health, and a client with minimal sunlight exposure is at risk of vitamin D deficiency, which affects calcium absorption. Therefore, this choice would worsen the client's situation.
Choice B rationale:
Using sunscreen with an SPF of 8 is unlikely to provide adequate protection against the harmful effects of sunlight. Moreover, the client's issue is vitamin D deficiency due to minimal sunlight exposure, and using sunscreen would further hinder vitamin D synthesis.
Choice C rationale:
Taking vitamin D supplements is the most appropriate intervention. Vitamin D is synthesized in the skin upon exposure to sunlight, and since the client has minimal sunlight exposure, supplements are necessary to prevent vitamin D deficiency. This choice addresses the root cause of the issue.
Choice D rationale:
Using a tanning bed is not recommended for increasing vitamin D levels. Tanning beds emit ultraviolet (UV) radiation, which can increase the risk of skin cancer. Moreover, excessive UV exposure is not a safe or controlled method for addressing vitamin D deficiency.
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