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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. In three-point gait crutch walking, the client should progress to foot touchdown and weight bearing of the affected leg. This means that the client is able to advance the crutches forward, followed by the affected leg, and then the unaffected leg. The weight should be borne primarily by the hands and arms on the crutches while the affected leg supports some weight as tolerated.
A. Bearing body weight on the palms of hands during the crutch gait describes the correct distribution of weight on the crutches, which is important for proper technique, but it does not specifically address the coordination of crutch and leg movements in three-point gait.
C. Practices bicep and triceps isometric exercises is not directly related to proper crutch walking technique but may be beneficial for strengthening the upper extremities, which are involved in using crutches.
D. Inspects crutches to ensure rubber tips are intact is important for safety but does not specifically indicate understanding of proper crutch walking technique.
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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