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 ["A","B","C"]
Explanation
Choice A rationale:
Spinach is one of the most nutrient-dense vegetables. Just 1 cup (190 grams) of frozen spinach packs 12% of the DV for potassium. It’s also loaded with other nutrients. The same serving of frozen spinach contains 127% of the DV for vitamin A, 857% for vitamin K, 58% for folate, and 37% for magnesium.
Choice B rationale:
Potatoes are a staple food and are high in potassium. They are a versatile and filling food that can be included in a variety of dishes. Potatoes are also a good source of vitamin C and dietary fiber.
Choice C rationale:
Bananas are known as potassium-rich foods. A medium banana contains around 9% of the DV for this mineral. Most people consider it the go-to food to increase their potassium intake. However, bananas are not the only good source of potassium.
Choice D rationale:
Apples are a healthy choice and provide some potassium, but they are not as high in potassium as the other choices. Therefore, while apples are a good part of a balanced diet, they would not be the first recommendation for someone needing to increase their potassium intake.
Correct Answer is ["A","D"]
Explanation
Choice A rationale:
Crackles are a common symptom of pleural effusion. They are abnormal lung sounds that are heard when a patient with pleural effusion breathes in. The sound is caused by the opening of small airways and alveoli collapsed by fluid, exudate, or lack of aeration during expiration.
Choice B rationale:
Crepitus is not typically associated with pleural effusion. Crepitus is a crackling or grating sound or feeling produced by air in subcutaneous tissue or by the rubbing together of fragments of broken bone. In the context of respiratory health, crepitus might be felt if there is subcutaneous emphysema, where air gets into tissues under the skin covering the chest wall or neck.
Choice C rationale:
Substernal retractions are not a typical symptom of pleural effusion. Retractions are a sign of respiratory distress, but they are more commonly associated with conditions that cause upper airway obstruction or severe lung disease, such as asthma or pneumonia. Choice D rationale:
Dullness upon percussion is a classic sign of pleural effusion. When there is fluid in the pleural space, it prevents the normal resonant sound produced by the air-filled lungs from being heard. Instead, a dull sound is heard when the chest is percussed.
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