The charge nurse brings a #18 urinary catheter with a 30 mL balloon to the practical nurse (PN) who is preparing to insert a catheter in a female client who weighs 50 kg. Which action should the PN take first?
Obtain a 30 mL syringe and a vial of sterile water.
Ask the client if she has previously been catheterized.
Consult with the charge nurse about the catheter.
Position the client and observe the urinary meatus.
The Correct Answer is C
This is the first action that the PN should take because the catheter size and balloon volume are inappropriate for the client. A #18 urinary catheter is too large for a female client who weighs 50 kg, and a 30 mL balloon may cause bladder trauma or discomfort. The PN should consult with the charge nurse and obtain a smaller catheter (such as #14 or #16) with a 10 mL balloon.
A. Obtaining a 30 mL syringe and a vial of sterile water is not the first action because it does not address the issue of the catheter size and balloon volume.
B. Asking the client if she has previously been catheterized is not the first action because it does not address the issue of the catheter size and balloon volume.
D. Positioning the client and observing the urinary meatus is not the first action because it does not address the issue of the catheter size and balloon volume.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is the factor that the PN should consider the most likely to increase the client's risk for falls because it can cause orthostatic hypotension, dizziness, or fainting, especially when the client changes position or gets up from bed or a chair. The PN should monitor the client's blood pressure and pulse before and after administering the medication and assist the client with ambulation and transfers.
Correct Answer is D
Explanation
The correct answer is choice D. Cleanse the finger with soap and water.
Choice A rationale:
Explaining the occurrence to the client is not the first action the PN should take in this situation. The priority is to address the potential exposure to bloodborne pathogens and ensure the PN's safety.
Choice B rationale:
Observing the appearance of the injection site is important for routine assessment but is not the first action the PN should take after getting stuck with the used needle. Immediate action to clean the wound site is essential to reduce the risk of infection.
Choice C rationale:
While notifying the charge nurse about the incident is important, it should not be the first action taken. The PN's safety should be addressed first by cleansing the finger.
Choice D rationale:
The PN should first cleanse the finger with soap and water immediately after getting stuck with the used needle. This action helps reduce the risk of infection and contamination. After cleansing, the PN can follow the facility's protocol for reporting incidents and seek necessary medical attention if required.
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