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 D
Explanation
The correct answer is choice D.
Choice A rationale:
Rinsing forearms with running water before applying soap is not a recommended step in the handwashing procedure. The primary step is to wet the hands, apply soap, and create a lather.
Choice B rationale:
Holding hands above elbow level while washing and rinsing is not a standard practice for handwashing. The hands should be washed thoroughly, and the focus is on scrubbing the hands, not their positioning.
Choice C rationale:
Generating a lather by rubbing hands together vigorously for 5 seconds is insufficient for effective handwashing. Proper handwashing involves rubbing hands together for at least 20 seconds to ensure thorough cleaning.
Choice D rationale:
The correct answer. After washing and drying hands, turning off the faucet with a clean paper towel is recommended to avoid recontaminating the clean hands. Touching the faucet directly with clean hands could potentially transfer pathogens back onto the hands.
Correct Answer is B
Explanation
The correct answer is choice B: A client who has measles.
Choice A rationale:
Airborne precautions are indicated for diseases that spread via small particles suspended in the air, such as droplets or dust particles that remain in the air for prolonged periods. Pneumonia is primarily spread through larger respiratory droplets and is not considered an airborne disease. Therefore, airborne precautions are not necessary for a client with pneumonia.
Choice B rationale:
Measles is a highly contagious airborne disease caused by the measles virus. It is transmitted through respiratory droplets and can remain in the air for an extended period. Initiating airborne precautions, such as wearing an N95 respirator mask and placing the client in a negative pressure isolation room, is crucial to prevent the spread of measles to healthcare workers and other patients.
Choice C rationale:
Pertussis (whooping cough) is primarily spread through respiratory droplets, similar to pneumonia. While it is a serious bacterial infection, it is not classified as an airborne disease. Thus, airborne precautions are not required for a client with pertussis.
Choice D rationale:
Methicillin-resistant Staphylococcus aureus (MRSA) is mainly spread through direct contact with contaminated surfaces or individuals. Airborne precautions are not necessary for MRSA, as it is not transmitted through the air. Standard precautions, including wearing gloves and gowns, are typically sufficient when caring for a client with MRSA.
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