The nurse is inserting a urinary catheter that has been prescribed for the client. When the tip of the catheter reemerges from the insertion site, which action should the nurse take next?

Increase the lighting in the room.

Obtain a new catheter.

Clean the catheter with providone-iodine.

Reposition the legs before reinsertion.

Answer and Explanation

The Correct Answer is B

B. If the tip of the urinary catheter reemerges from the insertion site during insertion, it means that the catheter has become contaminated with microorganisms from the urethra or surrounding area. Continuing to insert the same catheter can introduce these microorganisms into the urinary tract, increasing the risk of urinary tract infection (UTI).

A. Increasing the lighting in the room allows for optimal visualization during the procedure, but it is not the priority action when the catheter has become contaminated.

C. Cleaning the catheter with providone-iodine is not sufficient to sterilize the catheter and eliminate the risk of introducing pathogens into the urinary tract.

D. Repositioning the legs before reinsertion does not address the contamination of the catheter and does not mitigate the risk of introducing pathogens into the urinary tract.

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Correct Answer is B

Explanation

B. The needle should be inserted with the bevel facing up (visible through the skin). The goal is to deposit the medication into the epidermal layer (not subcutaneous tissue).

A. Massaging the site after injection can cause the medication to spread beyond the intended area, leading to inaccurate results or potential complications.

C. The correct angle for an intradermal injection is 5 to 15-degree angle. This angle allows for proper placement of the medication just below the epidermis.

D. Intradermal injections are usually administered on the forearm or the upper back, where the skin is thin and easily lifted to create a wheal.

A. Administer PRN oral pain medication. B. Monitor the client's nonverbal behavior. C. Ask the client what is causing the grimacing. D. Review the pain medications prescribed.

Correct Answer is C

Explanation

A. Administering pain medication solely based on nonverbal cues without further assessment and confirmation of pain may lead to unnecessary medication administration and potential adverse effects.

B.Monitoring the client's nonverbal behavior is crucial in this situation because it can provide valuable insight into the client's pain experience. However, this shoudl come after listening to the client first.

C. Directly asking the client about the grimacing is a very reasonable approach. Since the client denies pain but is exhibiting nonverbal signs of discomfort, the nurse could ask specific questions to explore whether there is another underlying cause.

D. Reviewing the pain medications prescribed is important to ensure that the client is receiving appropriate pain management, but it may not be the most immediate intervention in this scenario.

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The nurse is inserting a urinary catheter that has been prescribed for the client. When the tip of the catheter reemerges from the insertion site, which action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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