A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan to take?
Don sterile gloves before inserting the indwelling urinary catheter.
Apply an oil-based lubricant to the indwelling urinary catheter.
Use one cotton swab to clean the client’s genitalia.
Test the balloon on the indwelling urinary catheter before insertion.
The Correct Answer is A
Choice A rationale
Donning sterile gloves before inserting the indwelling urinary catheter is a critical step to prevent infection. The urinary tract is normally sterile, and using sterile gloves helps maintain this sterility during the procedure.
Choice B rationale
Applying an oil-based lubricant to the indwelling urinary catheter is not recommended. Oil- based lubricants can damage latex catheters and increase the risk of infection. A water-soluble lubricant is typically used.
Choice C rationale
Using one cotton swab to clean the client’s genitalia is not sufficient. Proper cleaning and disinfection of the area are crucial to prevent introducing bacteria into the urinary tract during catheter insertion.
Choice D rationale
Testing the balloon on the indwelling urinary catheter before insertion is not typically done. The balloon is usually inflated with sterile water once the catheter is in place to ensure that it remains in the bladder.
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Related Questions
Correct Answer is AANDD
Explanation
Choice A rationale
An ileostomy involves creating a stoma, or opening, in the abdominal wall. The location of the stoma is typically in the right lower abdomen.
Choice B rationale
The end of the stoma should not be painful after the procedure. If the patient experiences pain, it could indicate a complication and should be reported to the healthcare provider.
Choice C rationale
The patient should not expect the stoma to be a purple color. A healthy stoma should be red or pink. A purple stoma could indicate a lack of blood flow, which is a serious issue that needs immediate medical attention.
Choice D rationale
After an ileostomy, the patient will have liquid or semi-liquid stool pass through the stoma. This is because the large intestine, which normally absorbs water and forms solid stool, is bypassed or removed in the procedure.
Correct Answer is B
Explanation
Choice A rationale
Visual aids can be very helpful for patients with impaired speech. They can use pictures, written words, or devices to help express their thoughts2324.
Choice B rationale
Allowing extra time to communicate with the patient is crucial. It can reduce frustration and improve the effectiveness of communication2324.
Choice C rationale
Completing sentences for the patient can be disrespectful and may not accurately convey the patient’s thoughts2324.
Choice D rationale
Asking open-ended questions can be challenging for a person with impaired speech. It’s better to ask yes/no questions or use other communication strategies2324.
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