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 B
Explanation
Choice A rationale
A stoma may appear red and moist immediately after surgery, similar to the inside of the mouth. A purplish color could indicate a lack of blood supply to the stoma, which is a medical emergency.
Choice B rationale
A small amount of bleeding around the stoma is normal, especially when cleaning the area or changing the ostomy appliance. This is because the stoma contains blood vessels and has a rich blood supply.
Choice C rationale
Fecal output from a colostomy can be expected within 2 to 4 days after surgery. It is not typical to see output within 24 hours.
Choice D rationale
An increase in the intake of raw vegetables is not necessary after a colostomy. In fact, some people may find certain raw vegetables difficult to digest and they may cause gas or odor.
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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