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 Choice C: 3+ pitting edema.
Choice A rationale:
1+ pitting edema refers to mild pitting edema. It is characterized by a slight indentation that disappears rapidly. A measurement of 6 mm edema is beyond the scope of 1+ pitting edema.
Choice B rationale:
2+ pitting edema indicates moderate pitting edema. It is characterized by a deeper indentation that takes a few seconds to rebound. While 6 mm edema might be associated with 2+ pitting edema, it is not the most accurate description.
Choice C rationale:
3+ pitting edema signifies moderately severe pitting edema. It is characterized by a noticeable indentation that remains for a short duration. A measurement of 6 mm edema aligns with 3+ pitting edema, making it the correct choice.
Choice D rationale:
4+ pitting edema represents severe pitting edema. It is characterized by a deep indentation that persists for a significant amount of time. 6 mm edema is not typically associated with 4+ pitting edema.
Correct Answer is ["B","C","D"]
Explanation
The correct answer is choice b. Wash hands after removing gloves, c. Use antimicrobial hand gel after refilling a client’s water pitcher, and d. Clean the stethoscope with an antimicrobial wipe after obtaining vital signs.
Choice A rationale:
Placing immunocompromised clients in the same room can increase the risk of cross-infection among them. It is better to isolate them or place them in rooms with clients who have similar infection risks.
Choice B rationale:
Washing hands after removing gloves is crucial to prevent the spread of pathogens that might have contaminated the gloves during patient care.
Choice C rationale:
Using antimicrobial hand gel after refilling a client’s water pitcher helps to maintain hand hygiene and prevent the transmission of infections.
Choice D rationale:
Cleaning the stethoscope with an antimicrobial wipe after obtaining vital signs is essential to prevent the transfer of pathogens between patients.
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