A nurse is teaching a newly licensed nurse about the function of the large intestine. Which of the following information should the nurse include?
It produces vitamin D.
It absorbs liquid to form stool.
It prevents the reflux of food into the esophagus.
It secretes enzymes to digest food.
The Correct Answer is C
A. The nurse coats the indwelling urinary catheter with lubricant. This is correct procedure and requires no intervention. Lubricating the catheter reduces friction and discomfort during insertion.
B. The nurse applies the sterile drape prior to inserting the urinary catheter. This is correct procedure and requires no intervention. The sterile drape maintains a sterile field.
C. The nurse separates the client's labia with her dominant hand. The nurse should separate the client's labia with her non-dominant hand, which then remains in place as a "dirty" hand. The dominant hand, which remains sterile, is used to insert the catheter.
D. The nurse provides perineal care prior to inserting the urinary catheter. This is correct procedure and requires no intervention. Perineal care reduces the risk of introducing bacteria into the urinary tract.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The skin around the stoma is red: Redness around the stoma may indicate skin irritation, which is common but typically managed with proper skin care and is not always an urgent concern. However, if the redness is severe or associated with other symptoms, it should be monitored. Reporting may be necessary if it worsens.
B. The ostomy is draining frequently: Frequent drainage may be expected depending on the location of the colostomy and the client’s diet. While it should be monitored, frequent drainage alone does not necessarily indicate a problem that needs to be reported.
C. The stool is yellow-green: The color of stool can vary depending on diet, the location of the colostomy, and bile presence. Yellow-green stool is often expected in higher colostomies and may not need to be reported unless it is a sudden change.
D. The stoma is pale in color: A pale or dusky stoma can indicate compromised blood flow, which is a serious concern and should be reported to the provider immediately. A healthy stoma should be pink or red.
Correct Answer is B
Explanation
A. "You will wear an external collection bag to drain your urine." An external collection bag is required for an ileal conduit, not a neobladder, where urine is stored internally.
B. "You will have an internal pouch to store your urine." A neobladder is created using a portion of the intestine to form a new bladder, which stores urine internally. The client may be able to void through the urethra.
C. "You will have a stoma that is located in your abdomen." A stoma is associated with an ileal conduit or a urostomy, not with a neobladder. A neobladder does not require an external stoma.
D. "You will not be able to control your urination." Initially, the client may have difficulty controlling urination until they learn how to use the neobladder. Over time, they may regain some control.
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