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
None
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2250"]
Explanation
To calculate the total volume of IV fluid intake for the client, we need to add up the volumes of each type of fluid administered.
For 0.45% sodium chloride IV at 500 mL/hr for 3 hr:
Volume = Rate × Time = 500 mL/hr × 3 hr = 1500 mL
For 0.45% sodium chloride IV at 200 mL/hr for 3 hr:
Volume = Rate × Time = 200 mL/hr × 3 hr = 600 mL
For dextrose 5% in water at 75 mL/hr for 2 hr:
Volume = Rate × Time = 75 mL/hr × 2 hr = 150 mL
Total volume = 1500 mL + 600 mL + 150 mL = 2250 mL
Therefore, the nurse should document a total volume of 2250 mL for the client's IV fluid intake.
Correct Answer is D
Explanation
A. Loss of central vision: While loss of central vision can occur with various eye conditions, such as age-related macular degeneration, it is not specific to cataracts. Cataracts typically cause clouding of the lens, leading to blurred or dimmed vision rather than loss of central vision.
B. Increased intraocular pressure: Increased intraocular pressure is characteristic of conditions such as glaucoma, not cataracts. Cataracts involve clouding of the lens rather than elevated pressure within the eye.
C. Decrease in peripheral vision: Decreased peripheral vision is associated with conditions like retinitis pigmentosa or glaucoma but is not a typical finding in cataracts. Cataracts primarily affect visual acuity and clarity rather than peripheral vision.
D. A bluish-white colored pupil: A bluish-white appearance of the pupil, known as leukocoria or a white pupil reflex, can be indicative of cataracts. It occurs due to light scattering by the cloudy lens of the eye, resulting in an abnormal reflection from the pupil. This finding is characteristic of cataracts and warrants further evaluation by an ophthalmologist.
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