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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["35"]
Explanation
Step 1 is: To find out how many mL/hr the nurse should set the infusion pump to deliver, we need to divide the total volume of enteral nutrition (840 mL) by the total time (24 hours).
So, the calculation is: 840 mL ÷ 24 hours = 35 mL/hr Therefore, the nurse should set the infusion pump to deliver 35 mL/hr.
Correct Answer is D
Explanation
Choice A rationale
Fresh vegetables are generally not considered bladder irritants. They are part of a healthy diet and do not typically cause bladder irritation.
Choice B rationale
Red meat is not typically associated with bladder irritation. While some individuals may have specific dietary sensitivities, red meat is not commonly known to irritate the bladder.
Choice C rationale
Dairy products are not typically associated with bladder irritation. However, some individuals may have lactose intolerance or other specific sensitivities to dairy products.
Choice D rationale
Caffeinated beverages can irritate the bladder. Caffeine is a diuretic, which means it can increase urine production and potentially lead to bladder irritation.
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