ATI_Fundamental_of_nursing_exam_2Custom_NS_117_T_Winter_2023_Monroe
ATI_Fundamental_of_nursing_exam_2Custom_NS_117_T_Winter_2023_Monroe ( 43 Questions)
A charge nurse in a long-term care facility is observing another nurse who is inserting an indwelling urinary catheter into a female patient.
Which action by the nurse should prompt the charge nurse to intervene?
The nurse should not apply the sterile drape before cleaning the perineal area. This is because the sterile drape is meant to maintain a sterile field during the procedure. If the nurse applies the sterile drape before cleaning the perineal area, it could lead to contamination of the sterile field, increasing the risk of infection.
Lubricating the indwelling urinary catheter is a standard practice in catheter insertion. This is done to minimize discomfort to the patient during the procedure. The lubricant used is usually water-soluble and does not interfere with the sterility of the catheter.
The nurse separating the patient’s labia with her dominant hand is a correct procedure. This is done to expose the urethral meatus for catheter insertion. The hand used to separate the labia is considered ‘clean’ rather than ‘sterile’, while the other hand, which is ‘sterile’, is used to handle the catheter.
Providing perineal care prior to inserting the urinary catheter is a correct procedure. This is done to reduce the risk of introducing bacteria into the urinary tract during catheter insertion. The perineal area should be cleaned from front to back to avoid contamination of the urethra.
Choice A rationale:
The nurse should not apply the sterile drape before cleaning the perineal area. This is because the sterile drape is meant to maintain a sterile field during the procedure. If the nurse applies the sterile drape before cleaning the perineal area, it could lead to contamination of the sterile field, increasing the risk of infection.
Choice B rationale:
Lubricating the indwelling urinary catheter is a standard practice in catheter insertion. This is done to minimize discomfort to the patient during the procedure. The lubricant used is usually water-soluble and does not interfere with the sterility of the catheter.
Choice C rationale:
The nurse separating the patient’s labia with her dominant hand is a correct procedure. This is done to expose the urethral meatus for catheter insertion. The hand used to separate the labia is considered ‘clean’ rather than ‘sterile’, while the other hand, which is ‘sterile’, is used to handle the catheter.
Choice D rationale:
Providing perineal care prior to inserting the urinary catheter is a correct procedure. This is done to reduce the risk of introducing bacteria into the urinary tract during catheter insertion. The perineal area should be cleaned from front to back to avoid contamination of the urethra.