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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A rationale

A purplish-colored stoma may indicate compromised circulation, which is a serious condition that requires immediate medical attention18.

Choice B rationale

A rosebud-like stoma orifice is a normal finding and does not need to be reported18.

Choice C rationale

A stoma oozing red drainage is a normal finding immediately after surgery and does not need to be reported18.

Choice D rationale

A shiny, moist stoma is a normal finding and does not need to be reported18.

A. Mix the three medications together prior to administering. B. Maintain the head of the bed in a flat position for 30 min following medication administration. C. Flush the NG feeding tube with 30 mL of water immediately following medication administration. D. Dilute each medication with 10 mL of tap water.

Correct Answer is C

Explanation

Rationale:

When administering multiple liquid medications through an NG tube, it’s important to administer each medication separately to prevent drug interactions. After each medication, the NG tube should be flushed with 30 mL of water to ensure that the medication has been fully administered and to prevent the tube from becoming clogged.

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A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan to take?

Nursing Test Bank

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