Nokea
The nurse is inserting an indwelling catheter into a female client. Which interventions should be implemented? Rank in the order of performance.
- A. Explain the procedure to the client.
- B. Set up the sterile field.
- C. Inflate the catheter bulb.
- D. Place absorbent pads under the client.
- E. Clean the perineum from clean to dirty with Betadine.
Correct Answer: A,D,B,E,C
Rationale: Correct order: 1) Explain the procedure to gain consent and reduce anxiety; 2) Place absorbent pads to maintain a clean field; 3) Set up the sterile field to prepare equipment; 4) Clean the perineum (front to back, not clean to dirty, assuming document error) to reduce infection risk; 5) Inflate the catheter bulb after insertion to secure it.
You may also like to solve these questions
The client diagnosed with chronic renal failure (CRF) is prescribed hemodialysis on Monday, Wednesday, and Friday. Which interventions should the nurse implement? Select all that apply.
- A. Weigh the client before and after each treatment.
- B. Discuss the recommended fluid restriction.
- C. Provide potato chips or pretzels as a snack.
- D. Monitor the hemodialysis access site continuously.
- E. Keep up a lively conversation during the treatments.
Correct Answer: A,B,D
Rationale: Weighing pre/post-dialysis assesses fluid removal, fluid restriction education prevents overload, and monitoring the access site prevents complications. Salty snacks increase thirst, and conversation is not a priority intervention.
When the client asks the nurse to clarify the surgeon's explanation of the procedure, which statement is most accurate?
- A. Your urine will be deposited in your small intestine.
- B. Urine will be eliminated with stool from the rectum.
- C. Urine will drain from an abdominal opening.
- D. Your urine will empty from a special catheter.
Correct Answer: C
Rationale: An ileal conduit diverts urine to an abdominal stoma, where it drains externally.
Which modifiable risk factor should the nurse identify for the development of cancer of the bladder in a client?
- A. Previous exposure to chemicals.
- B. Pelvic radiation therapy.
- C. Cigarette smoking.
- D. Parasitic infections of the bladder.
Correct Answer: C
Rationale: Cigarette smoking is a major modifiable risk factor for bladder cancer due to carcinogenic compounds in tobacco. Chemical exposure and radiation are risks but less modifiable, and parasitic infections are rare.
The client diagnosed with a urinary tract infection has a blood pressure of 83/56 mm Hg and a pulse of 122 bpm. Which should the nurse implement first?
- A. Notify the health-care provider (HCP).
- B. Hang the IVPB antibiotic at the prescribed rate.
- C. Check the laboratory work to determine if the urine culture has been completed.
- D. Increase the normal saline IV fluids from keep open to 150 mL/hour on the IV pump.
Correct Answer: D
Rationale: Hypotension (83/56) and tachycardia (122 bpm) suggest septic shock from the UTI. Increasing IV fluids to 150 mL/hour improves perfusion, stabilizing the client. Notification, antibiotics, and lab checks are secondary to immediate fluid resuscitation.
When the client with an ileal conduit expresses concern about odor, which recommendation by the nurse is most effective?
- A. Place an aspirin tablet in the pouch.
- B. Use a deodorizing pouch spray.
- C. Change the pouch daily.
- D. Avoid acidic foods.
Correct Answer: B
Rationale: Using a deodorizing pouch spray effectively controls odor, addressing the client's concern.