A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan to take?
Don sterile gloves before inserting the indwelling urinary catheter.
Apply an oil-based lubricant to the indwelling urinary catheter.
Test the balloon on the indwelling urinary catheter before insertion.
Use one cotton swab to clean the client's urinary meatus.
The Correct Answer is A
Choice A reason: Donning sterile gloves is an essential step to prevent contamination and infection during the insertion of an indwelling urinary catheter. The nurse should also use aseptic technique and a sterile catheter kit.
Choice B reason: Applying an oil-based lubricant to the indwelling urinary catheter is not recommended, as it can damage the latex material and increase the risk of catheter-associated urinary tract infection (CAUTI). The nurse should use a water-soluble lubricant instead.
Choice C reason: Testing the balloon on the indwelling urinary catheter before insertion is a good practice, as it ensures that the balloon is functioning properly and does not leak or burst. The nurse should inflate and deflate the balloon with sterile water or saline using a syringe.
Choice D reason: Using one cotton swab to clean the client's urinary meatus is not sufficient, as it may not remove all the bacteria and debris. The nurse should use at least three cotton swabs and clean the meatus from front to back in a circular motion. The nurse should also use an antiseptic solution such as chlorhexidine or povidone-iodine.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Planning to administer insulin to the client is not a relevant action for the nurse to take, as it has no effect on respiratory alkalosis or hyperventilation. Insulin is used to lower blood glucose levels in patients with diabetes or hyperglycemia.
Choice B reason: Having the client breathe into a paper bag is a correct action for the nurse to take, as it helps to increase the carbon dioxide level in the blood and correct the alkalosis. Breathing into a paper bag creates a closed system that recycles the exhaled carbon dioxide and reduces the loss of carbon dioxide from the lungs.
Choice C reason: Planning to administer sodium bicarbonate to the client is not a correct action for the nurse to take, as it can worsen the alkalosis. Sodium bicarbonate is an alkali that can raise the pH of the blood and cause metabolic alkalosis. It is used to treat metabolic acidosis, not respiratory alkalosis.
Choice D reason: Having the client place their head between their knees is not a recommended action for the nurse to take, as it can impair the blood flow to the brain and cause fainting. It can also increase the respiratory rate and decrease the carbon dioxide level in the blood.
Correct Answer is D
Explanation
Choice A reason: Numbness of fingers is not a sign of respiratory acidosis. It can be caused by other conditions such as peripheral neuropathy, Raynaud's syndrome, or carpal tunnel syndrome.
Choice B reason: Abdominal pain is not a sign of respiratory acidosis. It can be caused by other conditions such as gastritis, appendicitis, or gallstones.
Choice C reason: Dry skin is not a sign of respiratory acidosis. It can be caused by other conditions such as dehydration, eczema, or hypothyroidism.
Choice D reason: Lethargy is a sign of respiratory acidosis, as it indicates a low level of oxygen and a high level of carbon dioxide in the brain. Lethargy is a state of reduced mental and physical activity, which can progress to confusion, coma, or death if not treated.
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