Free NCLEX-RN Exam Braindumps (page: 58)

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In cleansing the perineal area around the site of catheter insertion, the nurse would:

  1. Wipe the catheter toward the urinary meatus
  2. Wipe the catheter away from the urinary meatus
  3. Apply a small amount of talcum powder after drying the perineal area
  4. Gently insert the catheter another 12 inch after cleansing to prevent irritation from the balloon

Answer(s): B

Explanation:

(A) Wiping toward the urinary meatus would transport microorganisms from the external tubing to the urethra, thereby increasing the risk of bladder infection. (B) Wiping away from the urinary meatus would remove microorganisms from the point of insertion of the catheter, thereby decreasing the risk of bladder infection. (C) Talcum powder should not be applied following catheter care, because powders contribute to moisture retention and infection likelihood. (D) The catheter should never be inserted further into the urethra, because this would serve no useful purpose and would increase the risk of infection.



In cleansing the perineal area around the site of catheter insertion, the nurse would:

  1. Wipe the catheter toward the urinary meatus
  2. Wipe the catheter away from the urinary meatus
  3. Apply a small amount of talcum powder after drying the perineal area
  4. Gently insert the catheter another 12 inch after cleansing to prevent irritation from the balloon

Answer(s): B

Explanation:

(A) Wiping toward the urinary meatus would transport microorganisms from the external tubing to the urethra, thereby increasing the risk of bladder infection. (B) Wiping away from the urinary meatus would remove microorganisms from the point of insertion of the catheter, thereby decreasing the risk of bladder infection. (C) Talcum powder should not be applied following catheter care, because powders contribute to moisture retention and infection likelihood. (D) The catheter should never be inserted further into the urethra, because this would serve no useful purpose and would increase the risk of infection.



Which nursing implication is appropriate for a client undergoing a paracentesis?

  1. Have the client void before the procedure.
  2. Keep the client NPO.
  3. Observe the client for hypertension following the procedure.
  4. Place the client on the right side following the procedure.

Answer(s): A

Explanation:

(A) A full bladder would impede withdrawal of ascitic fluid. (B) Keeping the client NPO is not necessary. (C) The client may exhibit signs and symptoms of shock and hypertension. (D) No position change is needed after the procedure.



Which nursing implication is appropriate for a client undergoing a paracentesis?

  1. Have the client void before the procedure.
  2. Keep the client NPO.
  3. Observe the client for hypertension following the procedure.
  4. Place the client on the right side following the procedure.

Answer(s): A

Explanation:

(A) A full bladder would impede withdrawal of ascitic fluid. (B) Keeping the client NPO is not necessary. (C) The client may exhibit signs and symptoms of shock and hypertension. (D) No position change is needed after the procedure.






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