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
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Telling the client, "It's not your choice to be here, so you have to accept the treatment we plan for you," disregards the client's autonomy and right to make decisions about their own healthcare. In mental health settings, respecting a patient's autonomy and involving them in the decision-making process is crucial for ethical care. This statement does not address the client's fear or provide any reassurance.
Choice B rationale:
Choice C rationale:
Asking, "Why do you think your provider will prescribe you medications that will make you sleep?" attempts to explore the client's fear, but it may come across as dismissive or invalidating. It could make the client feel unheard or misunderstood, which is not ideal in this situation.
Choice D rationale:
Stating, "I will make sure that we respect your right to refuse medications," is the most appropriate response. It acknowledges the client's fear and reassures them that their autonomy will be respected. It opens the door for a discussion about the client's concerns, allowing them to express their fears and preferences. Respecting the client's right to refuse medications is fundamental to ethical nursing practice and patient-centered care.
Correct Answer is A
Explanation
- A is correct because aPTT (activated partial thromboplastin time) measures the effectiveness of heparin therapy and guides dosage adjustments.
- B is incorrect because PT (prothrombin time) measures the effectiveness of warfarin therapy, not heparin.
- C is incorrect because INR (international normalized ratio) is a standardized version of PT that also monitors warfarin therapy, not heparin.
- D is incorrect because WBC count (white blood cell count) measures the body's immune response and has no relation to heparin therapy.
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