A nurse is preparing to remove a patient’s urinary catheter.
After performing hand hygiene, what should the nurse do next?
Position the client supine.
Cleanse the perineal area with an antiseptic.
Deflate the balloon halfway and then pull out the catheter.
Have the client bear down during removal.
The Correct Answer is B
Choice A rationale:
Positioning the client supine is not the immediate next step after performing hand hygiene when preparing to remove a patient’s urinary catheter. While it is important to ensure the patient is in a comfortable and appropriate position for the procedure, the immediate next step should be focused on ensuring the area is clean to prevent infection.
Choice B rationale:
After performing hand hygiene, the nurse should cleanse the perineal area with an antiseptic. This is to ensure that the area is clean before proceeding with the removal of the urinary catheter. It helps to prevent the introduction of bacteria into the urinary tract, which could lead to a urinary tract infection. The use of an antiseptic is recommended to kill any potential pathogens that may be present.
Choice C rationale:
Deflating the balloon halfway and then pulling out the catheter is not the immediate next step after performing hand hygiene. This step is usually done later in the process. Before deflating the balloon, it is important to ensure that the area is clean to prevent infection. Moreover, deflating the balloon halfway could potentially cause discomfort or injury to the patient. The balloon should be fully deflated before the catheter is removed.
Choice D rationale:
Having the client bear down during removal is not the immediate next step after performing hand hygiene. This action might be suggested during the actual removal of the catheter to aid in the process, but it is not the immediate next step. The focus right after hand hygiene should be on cleaning the area to prevent infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
Choice A rationale:
Mitral valve stenosis is a condition characterized by a narrowing of the mitral valve in the heart, which can lead to a variety of symptoms. One of the most common symptoms of mitral valve stenosis is a heart murmur. This is due to the turbulent flow of blood caused by the narrowed valve. The murmur is typically heard during a physical examination when a healthcare provider listens to the heart with a stethoscope.
Choice B rationale:
Bradycardia, or a slower than normal heart rate, is not typically associated with mitral valve stenosis. While mitral valve stenosis can cause irregular heart rhythms, it does not typically cause the heart rate to slow down.
Choice C rationale:
Clubbing of the fingers is a physical symptom that involves changes in the areas under and around the nails and is typically associated with conditions that cause chronic low blood oxygen levels. While mitral valve stenosis can lead to shortness of breath and fatigue, it does not typically cause clubbing of the fingers.
Choice D rationale:
A barrel chest, characterized by an increased chest diameter, is typically associated with conditions that cause chronic overinflation of the lungs, such as chronic obstructive pulmonary disease (COPD). It is not a typical symptom of mitral valve stenosis.
In conclusion, while mitral valve stenosis can lead to a variety of symptoms, the most relevant to this question is a heart murmur. Other symptoms such as bradycardia, clubbing of the fingers, and a barrel chest are not typically associated with this condition.
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