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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

- A. This choice is correct because a child who has autism spectrum disorder often exhibits strict adherence to routines and rituals, and may become distressed or agitated when there are changes or disruptions to their usual patterns.

- B. This choice is incorrect because difficulty paying attention to tasks is not a specific manifestation of autism spectrum disorder, but rather a common symptom of attentiondeficit/hyperactivity disorder (ADHD). A child who has autism spectrum disorder may have difficulty focusing on tasks that are not of interest to them, but may also show intense concentration on tasks that are of interest to them.

- C. This choice is incorrect because disobedience to authority figures is not a specific manifestation of autism spectrum disorder, but rather a common behavior problem in children and adolescents. A child who has autism spectrum disorder may have difficulty understanding social cues and expectations, but may also show compliance and cooperation when given clear instructions and positive reinforcement.

- D. This choice is incorrect because excessive anxiety when separated from parents is not a specific manifestation of autism spectrum disorder, but rather a common symptom of separation anxiety disorder. A child who has autism spectrum disorder may have difficulty forming attachments and expressing emotions, but may also show affection and attachment to familiar people.

A. "I will administer aspirin to my child to treat pain or fever." B. "I will record an average of three readings from my child's peak expiratory flow meter." C. I will place carpet in my child's bedroom to control allergens." D. "I will make sure my child receives a yearly influenza immunization."

Correct Answer is D

Explanation

A: Incorrect. Aspirin can trigger asthma attacks in some children and should be avoided.

B: Incorrect. The peak expiratory flow meter should be used daily, not just when the child has symptoms, and the highest reading should be recorded, not the average.

C: Incorrect. Carpet can harbor dust mites, mold, and other allergens that can worsen asthma. It is better to have hardwood or tile floors and washable rugs.

D: Correct. Influenza immunization can prevent serious complications from respiratory infections in children with asthma.

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A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first?

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A nurse is preparing to insert an indwelling urinary catheter for a client.
Which of the following actions should the nurse take first?