A nurse is preparing to insert an indwelling urinary catheter for a patient.
What 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 patient’s urinary meatus.
Correct Answer : A,C,D
Choice A rationale:
Donning sterile gloves before inserting the indwelling urinary catheter is a standard practice in healthcare to prevent infection. The urinary tract is normally sterile, and the use of sterile gloves helps maintain this sterility during the catheter insertion process. Choice B rationale:
Oil-based lubricants should not be used with indwelling urinary catheters. These lubricants can damage the catheter material and increase the risk of infection. Instead, water-soluble lubricants are recommended as they do not damage the catheter and can reduce patient discomfort during the insertion process.
Choice C rationale:
Testing the balloon on the indwelling urinary catheter before insertion is a critical step. This is done to ensure that the balloon inflates and deflates properly. If the balloon does not function correctly, it could cause discomfort or injury to the patient during insertion and could fail to keep the catheter in place once inserted.
Choice D rationale:
Cleaning the patient’s urinary meatus with one cotton swab is a part of the standard procedure before inserting an indwelling urinary catheter. This step is taken to remove any bacteria present at the site of insertion, thereby reducing the risk of introducing bacteria into the bladder during the catheter insertion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Metabolic alkalosis Metabolic alkalosis is a condition that occurs when your body has too many bases. It can occur due to prolonged vomiting, use of diuretics, or an overuse of antacids. In the context of Chronic Obstructive Pulmonary Disease (COPD), metabolic alkalosis is not typically a direct result of the disease. COPD primarily affects the respiratory system and does not directly cause an imbalance of bases in the body.
Choice B rationale:
Respiratory acidosis Respiratory acidosis is a condition that occurs when the lungs can’t remove enough carbon dioxide (CO2). This leads to a buildup of CO2 in the body, causing the pH of the blood to decrease and become more acidic. This is the most common acid-base imbalance seen in patients with COPD1. COPD can cause an alteration in respiratory exchanges, leading to retention of CO21. The consequence of hypercapnia due to alteration of gas exchange in COPD patients mainly consists in an increase of H+ concentration and development of respiratory acidosis.
Respiratory alkalosis Respiratory alkalosis is a condition that occurs when there is too little carbon dioxide in the body, often due to hyperventilation. In the context of COPD, this is less likely because COPD patients often have difficulty expelling carbon dioxide, not an excess of it being expelled.
Choice D rationale:
Metabolic Acidosis Metabolic acidosis occurs when the body produces too much acid, or when the kidneys are not removing enough acid from the body. This can occur due to conditions such as kidney disease, lactic acidosis, or ketoacidosis. While COPD can have wide-ranging effects on the body, it does not typically cause metabolic acidosis directly.
Correct Answer is A
Explanation
Choice A rationale:
Caffeinated beverages are known to cause diarrhea. Caffeine naturally occurs in many foods and drinks, including coffee and chocolate. It speeds up the digestive system and can cause loose stools. In addition, caffeine can irritate the stomach lining during digestion. Therefore, it’s important for the nurse to educate the patient about the potential effects of caffeinated beverages on their digestive system.
Choice B rationale:
Low-fiber cereal is not typically associated with triggering diarrhea. In fact, foods that are low in fiber can actually help firm up stools and are often recommended for individuals experiencing diarrhea. Therefore, while it’s not harmful, it’s not a primary concern for patients with diarrhea.
Choice C rationale:
White rice is another food that does not typically cause diarrhea. Similar to low-fiber cereal, white rice can help firm up stools and is often recommended for individuals experiencing diarrhea. It’s not a primary concern for patients with diarrhea.
Choice D rationale:
Ripe bananas do not typically cause diarrhea. They are actually part of the BRAT diet (Bananas, Rice, Applesauce, Toast), which is often recommended for individuals experiencing diarrhea. Therefore, it’s not a primary concern for patients with diarrhea.
In conclusion, when educating a patient about food and drinks that can trigger diarrhea, the nurse should include caffeinated beverages as they can potentially cause diarrhea. However, low-fiber cereal, white rice, and ripe bananas are not typically associated with triggering diarrhea.
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