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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 C

Answer: C. Cleanse the client's meatus with antiseptic solution.

Rationale:

A. Lubricate the catheter with water-soluble gel:
While lubrication is an important step in the catheterization process, it is not the first action to take. Proper cleansing of the meatus is essential to minimize the risk of introducing bacteria into the urinary tract during the insertion of the catheter.

B. Position the sterile drape leaving the perineum exposed:
Setting up the sterile field is crucial, but the first priority should be to cleanse the meatus to prevent infection. The sterile drape should be positioned after ensuring the area is clean and before catheter insertion.

C. Cleanse the client's meatus with antiseptic solution:
This is the first action the nurse should take. Properly cleansing the meatus with antiseptic solution helps reduce the risk of urinary tract infections by eliminating bacteria from the area prior to catheter insertion. It is a critical step in maintaining aseptic technique during the procedure.

D. Attach a prefilled syringe to the catheter inflation hub:
Attaching the syringe for inflation is done after the catheter is inserted and positioned correctly. This action comes later in the procedure, once aseptic measures have been completed and the catheter is in place.

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Correct Answer is A

Explanation

A. Report sudden, persistent headaches: Sudden, persistent headaches can indicate a sickle cell crisis or complications such as stroke. Prompt reporting of these symptoms allows for timely intervention and management of potential complications.
B. Avoid meningococcal immunizations: Immunizations, including meningococcal vaccines, are essential for individuals with sickle cell anemia because they are at increased risk of infections, including those caused by encapsulated bacteria like Neisseria meningitidis. Immunizations help prevent serious infections and their complications.
C. Apply cold compresses to painful areas: Cold compresses are not recommended for individuals with sickle cell anemia. Heat therapy is typically used to alleviate pain associated with vaso-occlusive crises, which are common in sickle cell disease. Heat helps relax muscles and improve blood flow to the affected area, reducing pain and promoting healing.
D. Restrict fluid intake during times of stress: Individuals with sickle cell anemia should maintain adequate hydration at all times, especially during periods of stress or illness. Dehydration can exacerbate sickling of red blood cells and increase the risk of vaso-occlusive crises. Therefore, fluid intake should be encouraged, and restrictions should be avoided unless specifically advised by a healthcare provider.

A. "I can expect my eyelids to be bruised after this procedure. B. "I will see dark spots in my vision after this procedure." C. I will receive general anesthesia for this procedure." D. I know the provider will replace the lens in my eyes during this procedure."

Correct Answer is D

Explanation

A. "I can expect my eyelids to be bruised after this procedure": Bruising of the eyelids is not a common expectation following cataract removal surgery. While mild redness or irritation may occur, significant bruising is not typical.
B. "I will see dark spots in my vision after this procedure": Seeing dark spots in vision after cataract removal surgery is not expected. The purpose of cataract surgery is to improve vision by removing the cloudy lens and replacing it with a clear artificial lens. Dark spots in vision may indicate complications such as retinal detachment, which should be promptly reported to the healthcare provider.
C. "I will receive general anesthesia for this procedure": Cataract removal surgery typically does not require general anesthesia. Instead, it is commonly performed under local anesthesia with sedation. General anesthesia is reserved for more complex or high-risk procedures. Therefore, this statement indicates a misunderstanding of the anesthesia type for cataract surgery.
D. "I know the provider will replace the lens in my eyes during this procedure": This statement indicates an accurate understanding of the cataract removal procedure. During cataract surgery, the cloudy natural lens of the eye is removed and replaced with an artificial intraocular lens (IOL) to restore vision. This is the primary goal of the surgery, and the statement reflects the client's understanding of the procedure.

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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?

Rationale:

Nursing Test Bank

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