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 D

Explanation

A. Erythema (redness) and serosanguineous exudate (clear to blood-tinged fluid) are typical findings in the early stages of wound healing, especially within the first few days post-surgery. However, one week post-surgery, these signs should begin to decrease as the wound progresses through the inflammatory phase of healing.

B. Eschar (dry, black, or brown necrotic tissue) and slough (yellow or white soft tissue) are indicative of non-viable tissue and delayed wound healing.

C. Beefy red granulation tissue is a positive sign of healing. It indicates new tissue formation, which is essential for the healing process. Granulation tissue is typically moist, and its presence suggests that the wound is progressing well towards healing.

D.This indicates that the edges of the incision are properly closed and healing as expected.

A. Elevate the head of the bed to a 45-degree angle. B. Remove dentures or other oral appliance. C. Lift and lock the side rails in place. D. Apply the client's positive airway pressure device.

Correct Answer is D

Explanation

D. Severe obstructive sleep apnea poses a risk of respiratory compromise, particularly when compounded by the effects of opioid analgesics, which can depress respiratory drive. Applying the client's prescribed positive airway pressure (PAP) device, such as continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP), helps maintain airway patency and ensures adequate ventilation

A. It promotes better alignment of the airway, decreasing the likelihood of obstruction by the tongue or soft tissues. While this intervention is beneficial for managing OSA, it may not be the most critical intervention in this context.

B. Removing dentures or oral appliances may be necessary to prevent airway obstruction, especially during sleep when muscle tone is decreased. However, it is not the most critical intervention in this scenario

C. Securing side rails is important for client safety, especially in postoperative settings where clients may be at risk of falls. However, it does not directly address the client's obstructive sleep apnea or potential respiratory compromise from opioid administration.

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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 D

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Correct Answer is D

Explanation

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