A nurse who is left-handed is preparing to perform a straight catheterization for a client. Which of the following actions should the nurse take?
Raise the bed to a comfortable height.
Stand on the left side of the bed
Raise the side rat on the working side of the bed.
Use the non-dominant hand to insert the catheter.
The Correct Answer is A
A. Raise the bed to a comfortable height:
Raising the bed to a comfortable height is essential for proper body mechanics and preventing back strain. It ensures the nurse can perform the procedure efficiently and safely.
B. Stand on the left side of the bed:
While a left-handed nurse might prefer to stand on the left side for better access, this choice depends on the room layout and client position. Standing on the side where the nurse is most comfortable is essential, but it is not the primary action compared to ensuring proper bed height.
C. Raise the side rail on the working side of the bed:
Raising the side rail on the working side of the bed could obstruct the nurse's access to the client and is not generally recommended during procedures requiring close access to the client.
D. Use the non-dominant hand to insert the catheter:
The dominant hand, in this case, the left hand, should be used to insert the catheter for better control and precision. The non-dominant hand is typically used to hold the genitalia and provide stability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Viral infection:
Chronic stress can suppress the immune system, making individuals more susceptible to infections, including viral infections. Prolonged stress can dysregulate the immune response, leading to increased vulnerability to various illnesses.
B) Increased cognitive awareness:
Chronic stress often impairs cognitive function rather than enhancing it. It can lead to difficulties with concentration, memory problems, and cognitive fatigue due to the continuous activation of the body's stress response system.
C) Hypotension:
Chronic stress typically leads to increased blood pressure rather than hypotension. Stress activates the sympathetic nervous system, resulting in the release of stress hormones like cortisol and adrenaline, which can elevate blood pressure over time.
D) Increased energy:
While acute stress can trigger a temporary surge in energy due to the release of stress hormones, chronic stress often leads to fatigue and exhaustion. Prolonged activation of the stress response system can deplete energy reserves and disrupt sleep patterns, resulting in feelings of fatigue and lethargy.
Correct Answer is C
Explanation
A. Check residual volume every 4 to 6 hr: While checking residual volume is an essential component of enteral feeding management, it is not the priority action in this scenario. The client's positioning to prevent aspiration takes precedence over checking residual volume.
B. Observe client's respiratory status: Monitoring respiratory status is crucial for any client with a decreased level of consciousness. However, in this case, the priority is to prevent aspiration, and positioning takes precedence over respiratory assessment.
C. Elevate the head of the client's bed 30° to 45°: The priority action for a client receiving continuous enteral feedings via a gastrostomy tube and experiencing a decreased level of consciousness is to maintain proper positioning to prevent aspiration. Elevating the head of the bed 30° to 45° helps reduce the risk of aspiration by promoting drainage of stomach contents away from the airway. This position also helps prevent reflux of gastric contents into the esophagus, which can lead to aspiration pneumonia.
D. Monitor intake and output every 8 hr: Monitoring intake and output is essential for assessing fluid balance and the effectiveness of enteral feedings. However, it is not the priority action in this situation compared to maintaining proper positioning to prevent aspiration.
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