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

Use one cotton swab to clean the client's urinary meatus.

Don sterile gloves before inserting the indwelling urinary catheter.

Test the balloon on the indwelling urinary catheter before insertion.

Apply an oil-based lubricant to the indwelling urinary catheter.

Answer and Explanation

The Correct Answer is B

A. Use one cotton swab to clean the client's urinary meatus: Multiple cotton swabs should be used to clean in a systematic manner to maintain asepsis.

B. Don sterile gloves before inserting the indwelling urinary catheter. Sterile technique is essential to prevent urinary tract infections (UTIs) during catheter insertion.

C. Test the balloon on the indwelling urinary catheter before insertion: Pretesting the balloon is unnecessary and may compromise sterility or damage the balloon.

D. Apply an oil-based lubricant to the indwelling urinary catheter: Only water-based lubricants should be used to prevent catheter damage or client harm.

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Correct Answer is B

Explanation

A. Obtain a prescription to check the client's glucose level: Incorrect. While glucose monitoring is essential, addressing hypoxia takes precedence.

B. Obtain a prescription for supplemental oxygen: Hypoxia is life-threatening and must be addressed first to restore oxygenation and prevent further complications. The priority aligns with the Airway, Breathing, Circulation (ABC) framework.

C. Obtain a prescription to administer intravenous fluids: Incorrect. IV fluids are critical for DKA management, but oxygenation is a higher priority if hypoxia is present.

D. Obtain a prescription to administer insulin: Incorrect. Insulin is necessary to correct hyperglycemia in DKA but is not the immediate priority over addressing hypoxia.

A. "You should expect your stoma to be a purple color." B. "The end of the stoma will be painful after this procedure." C. "Your colostomy will not produce formed stool." D. "You will have a stoma in your left lower abdomen."

Correct Answer is D

Explanation

A. "You should expect your stoma to be a purple color.": Incorrect. A healthy stoma should be pink to red; a purple stoma indicates compromised blood flow and requires immediate medical attention.

B. "The end of the stoma will be painful after this procedure.": Incorrect. Stomas lack pain receptors, so the client should not feel pain directly at the stoma site.

C. "Your colostomy will not produce formed stool.": Incorrect. A sigmoid colostomy produces stool that is typically more formed because it involves the lower part of the colon.

D. "You will have a stoma in your left lower abdomen.": A sigmoid colostomy is typically located in the left lower quadrant because it involves the sigmoid colon.

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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 take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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