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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Spinach is a good source of potassium, but not the best. According to the USDA, one cup of cooked spinach contains 839 mg of potassium, which is about 18% of the recommended daily intake (RDI) for adults².
Choice B reason: Baked potato is the best source of potassium among the choices. According to the USDA, one medium baked potato with skin contains 941 mg of potassium, which is about 20% of the RDI for adults². Potassium is an essential mineral that helps regulate fluid balance, nerve and muscle function, and blood pressure.
Choice C reason: Banana is a popular source of potassium, but not the best. According to the USDA, one medium banana contains 422 mg of potassium, which is about 9% of the RDI for adults².
Choice D reason: Cheese is a poor source of potassium. According to the USDA, one ounce of cheddar cheese contains only 28 mg of potassium, which is less than 1% of the RDI for adults². Cheese is high in sodium, which can counteract the benefits of potassium and increase the risk of hypertension.
Correct Answer is D
Explanation
Choice A reason: Stripping the client's chest tube every 2 hours is not a recommended action, as it can cause excessive negative pressure, tissue trauma, and pain. The nurse should only strip the chest tube if there is a clot or obstruction in the tubing, and only with the provider's order.
Choice B reason: Looping the tubing of the chest tube on the client's bed is a correct action, as it prevents kinking, tension, or pulling on the chest tube. The nurse should also secure the tubing to the bed sheet with a safety pin.
Choice C reason: Placing the chest tube drainage system above the level of the client's heart is not a correct action, as it can cause the fluid to flow back into the chest cavity and impair lung expansion. The nurse should place the chest tube drainage system below the level of the client's chest.
Choice D reason: Taping the connections on the client's chest tube is a correct action, as it prevents air leaks, disconnections, or accidental removal of the chest tube. The nurse should also check the connections regularly for tightness and patency.
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