A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan to take?
Test the balloon on the indwelling urinary catheter before insertion.
Use one cotton swab to clean the client's urinary meatus.
Don sterile gloves before inserting the indwelling urinary catheter.
Apply an oil-based lubricant to the indwelling urinary catheter.
The Correct Answer is C
Choice A reason: Testing the balloon is important, but it is not the action to take immediately before insertion.
Choice B reason: While cleaning the urinary meatus is necessary, using one cotton swab is not sufficient for proper aseptic technique.
Choice C reason: Donning sterile gloves is essential to maintain an aseptic technique during catheter insertion to prevent infection.
Choice D reason: An oil-based lubricant should not be used as it can increase the risk of infection and is not compatible with the catheter material; a water-soluble lubricant is recommended.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Wearing sterile gloves is not necessary when draining an ileostomy bag as this is not a sterile procedure. Clean gloves are typically used.
Choice B reason: Washing the skin surrounding the ileostomy with hot water is not recommended as it can cause
irritation. Lukewarm water should be used, and the area should be patted dry.
Choice C reason: Cleaning the end of the ileostomy pouch before clamping is important to maintain hygiene and
prevent contamination when draining the bag.
Choice D reason: The ileostomy bag should be emptied when it is one-third to one-half full to prevent leakage and ensure comfort for the client.
Correct Answer is B
Explanation
Choice A reason: Infusing 0.9% sodium chloride is not the immediate action to take when a transfusion reaction is suspected. The priority is to stop the transfusion and address the reaction.
Choice B reason: Obtaining a blood sample from the client is necessary to perform laboratory tests to confirm the transfusion reaction and to identify the cause.
Choice C reason: Returning the unit of blood to the blood bank is done after the transfusion has been stopped and the reaction has been addressed. It is important for the blood bank to know about the reaction to investigate the cause.
Choice D reason: Notifying the charge nurse is important, but the first action should be to stop the transfusion and maintain the client's safety. The charge nurse can then assist with the subsequent steps.
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