Try Naxlex NCLEX-RN (Free-Trial)

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

Lubricate the catheter with water-soluble gel.

Position the sterile drape leaving the perineum exposed.

Cleanse the client's meatus with antiseptic solution.

Attach a prefilled syringe to the catheter inflation hub.

None

Answer and Explanation

The Correct Answer is B

Correct Answer: B. Position the sterile drape leaving the perineum exposed.

Rationales

A. Lubricate the catheter with water-soluble gel.
Lubrication is important to reduce urethral trauma, but this is not the first step once the sterile field is prepared. It comes after draping and cleansing, just before catheter insertion.

B. Position the sterile drape leaving the perineum exposed.
This is the first action after donning sterile gloves and preparing the field. Draping maintains a sterile environment and provides access to the insertion site. Ensuring sterility from the beginning is critical for preventing catheter-associated infections.

C. Cleanse the client’s meatus with antiseptic solution.
Cleansing the meatus is done after draping to reduce the risk of introducing microorganisms during catheter insertion. Although essential, it is not the very first step once the sterile procedure begins.

D. Attach a prefilled syringe to the catheter inflation hub.
The balloon should not be prepared or inflated until after the catheter has been inserted and urine return is observed. Attaching the syringe too early may risk accidental inflation outside the bladder.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Lift the traction weights when repositioning the child in bed.

This action should not be included in the plan of care because lifting the traction weights can interfere with the traction's effectiveness and potentially cause harm or injury to the child. The weights are specifically calibrated to provide the necessary tension for the traction to stabilize the fracture site.

B. Have the child rate their level of pain every 8 hours.

While pain assessment is an essential component of nursing care, the frequency of every 8 hours may not be sufficient, especially for a child in skeletal traction. Pain management should be more frequent and individualized based on the child's needs, which may vary throughout the day.

C. Monitor the neurovascular status of the child's lower extremities every 12 hours.

Neurovascular assessment is crucial for patients in traction to detect any signs of compromised circulation or nerve function. However, every 12 hours may not be frequent enough to promptly identify changes in neurovascular status. More frequent assessments, such as every 1-2 hours initially and then gradually decreasing based on stability, are typically recommended.

D. Educate the child's guardians about pin site care prior to discharge.

This is the correct answer. Educating the child's guardians about pin site care is essential to prevent infection and other complications associated with skeletal traction. Proper care of the pin sites reduces the risk of infection, which can lead to serious complications such as osteomyelitis. Providing education prior to discharge ensures that the guardians are equipped with the necessary knowledge and skills to care for the child at home effectively.

A. Insomnia B. Constipation C. Dry mouth D. Excessive sweating

Correct Answer is D

Explanation

A. Insomnia: While insomnia can be a side effect of sertraline, it is not typically associated with serotonin syndrome. However, if the insomnia is severe or accompanied by other symptoms of serotonin syndrome, it should be reported to the healthcare provider.
B. Constipation: Constipation is a common side effect of sertraline but is not indicative of serotonin syndrome. It is important to monitor for constipation and manage it appropriately but not as an indicator of serotonin syndrome.
C. Dry mouth: Dry mouth is another common side effect of sertraline but is not specific to serotonin syndrome. While uncomfortable, it does not typically require immediate reporting unless severe or accompanied by other concerning symptoms.
D. Excessive sweating: Excessive sweating, also known as diaphoresis, is a hallmark symptom of serotonin syndrome. It is a significant indicator of serotonin toxicity and should be reported immediately to the healthcare provider for further evaluation and management.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Correct Answer: B. Position the sterile drape leaving the perineum exposed.

Rationales

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a child who is in skeletal traction following a femur fracture. Which of the following actions should the nurse include in the plan?

Correct Answer is D

Explanation

A nurse is teaching a client who has a new prescription for sertralihe to treat depression. For which of the following findings should the nurse instruct the client to monitor and report immediately as indicating serotonin syndrome?

Correct Answer is D

Explanation

A nurse is caring for four children in an emergency department. Which of the following clients should the nurse assess first?

A charge nurse is evaluating a newly licensed nurse who is caring for a client who has measles. For which of the following actions by the newly licensed nurse should the charge nurse intervene?

A nurse is caring for a client following an involuntary admission to'an acute mental health facility. The client states, "I'm afraid they will give me drugs that put me to sleep." Which of the following statements should the nurse make?

A nurse is performing an eye examination on a client. Which of the following findings should indicate to the nurse that the client might have cataracts?

A nurse is teaching a client who is at 20 weeks of gestation about how to manage heartburn. Which of the following instructions should the nurse include?

A nurse is caring for a client who is experiencing seizures due to alcohol withdrawal. Which of the following medications should the nurse plan to administer?

A nurse is planning care for a client who is at 32 weeks of gestation and has severe preeclampsia. Which of the following actions should the nurse plan to take?

A community health nurse is providing education to a group of older adults about immunizations. Which of the following immunizations should the nurse recommend?