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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 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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Answer: A

Rationale: A) "Empty your ostomy pouch when it is half full.": This instruction is essential to prevent the pouch from becoming too heavy, which can cause leakage or discomfort. Regular emptying also helps maintain the integrity of the pouching system and prevents leaks.

B) "Notify the provider if your stoma becomes pink and moist.": While it's crucial to monitor the stoma's appearance for signs of complications, a pink and moist stoma typically indicates healthy tissue. This instruction may cause unnecessary concern for the client.

C) "Use a moisturizing soap to cleanse your stoma.": Moisturizing soap is not recommended for stoma cleansing, as it may leave a residue that interferes with the pouch's adhesion and can lead to skin irritation. Instead, the client should use warm water and a mild, non-moisturizing soap.

D) "Apply sterile gloves when changing your ostomy pouch.": While hand hygiene is essential when managing an ostomy, sterile gloves are not necessary for routine pouch changes. Clean, non-sterile gloves or thorough handwashing with soap and water are sufficient to prevent infection.

A. Contact B. Airborne C. Protective environment D. Droplet

Correct Answer is D

Explanation

A. Contact precautions are used for infections transmitted by direct or indirect contact with the client or their environment. Examples include MRSA, C. difficile, and other multidrug-resistant organisms.
B. Airborne precautions are used for infections transmitted by small droplets that remain suspended in the air and can be inhaled. Examples include tuberculosis (TB), measles, and chickenpox (varicella).
C. Protective environment precautions are typically used for clients with compromised immune systems, such as those undergoing stem cell transplants, to protect them from environmental pathogens.
D. Droplet precautions are used for infections transmitted by large respiratory droplets that can travel up to approximately 3 feet. Examples include bacterial meningitis, influenza, and pertussis. Therefore, the nurse should initiate droplet precautions for the school-age child with bacterial meningitis.

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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 take first?

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

Rationales

Nursing Test Bank

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