A nurse is preparing to insert an indwelling urinary catheter for a client.
Which of the following actions should the nurse take first?
Attach a prefilled syringe to the catheter inflation hub.
Position the sterile drape leaving the perineum exposed.
Cleanse the client's meatus with antiseptic solution.
Lubricate the catheter with water-soluble gel.
The Correct Answer is C
Choice A rationale:
Attaching a prefilled syringe to the catheter inflation hub is a step performed after the catheter insertion to inflate the balloon, securing the catheter in the bladder. This action is not the first step and should not be done before cleansing the meatus and positioning the sterile drape.
Choice B rationale:
Positioning the sterile drape leaving the perineum exposed is a necessary step in maintaining the sterility of the procedure area. However, it is not the first action the nurse should take. Cleaning the client's meatus with an antiseptic solution is the initial step to prevent infection during catheter insertion.
Choice C rationale:
Cleaning the client's meatus with antiseptic solution is the first step in inserting an indwelling urinary catheter. This action helps to reduce the risk of urinary tract infection by minimizing the introduction of bacteria into the urethra.
Choice D rationale:
Lubricating the catheter with water-soluble gel is a step performed after cleansing the meatus and positioning the sterile drape. It facilitates the smooth insertion of the catheter into the urethra. However, it is not the first action to be taken.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
- A is incorrect because diarrhea is not an adverse effect of clonidine, but rather a symptom of other conditions such as infection, inflammation, or food intolerance.
- B is correct because dry mouth is a common adverse effect of clonidine, which is an alpha-2 adrenergic agonist that reduces sympathetic nervous system activity.
- C is incorrect because photophobia, or sensitivity to light, is not an adverse effect of clonidine, but rather a symptom of other conditions such as migraine, eye injury, or infection.
- D is incorrect because bruising, or bleeding under the skin, is not an adverse effect of clonidine, but rather a symptom of other conditions such as coagulation disorders, vitamin deficiency, or trauma.
Correct Answer is A
Explanation
Advocacy is a leadership role that helps others to self-actualize.
- A. Advocacy is a leadership role that helps others to self-actualize. This statement is true and reflects one of the core principles of advocacy, which is to empower others to achieve their full potential and exercise their rights and responsibilities. This choice is correct.
- B. Subordinates are advocates for the nurse manager. This statement is false and contradicts one of the core principles of advocacy, which is to act in the best interest of those who are vulnerable or oppressed, not those who are in positions of power or authority. This choice is incorrect.
- C. Advocacy encourages clients to rely on health care staff for decision-making. This statement is false and contradicts one of the core principles of advocacy, which is to respect and support clients' autonomy and self-determination, not to impose or influence their choices or actions. This choice is incorrect.
- D. Nurse managers should distrust people who expose inappropriate professional practices. This statement is false and contradicts one of the core principles of advocacy, which is to promote and uphold ethical standards and quality of care, not to conceal or ignore malpractice or misconduct. This choice is incorrect.
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