A nurse is planning to insert a female external urinary catheter for a client.
Which of the following actions should the nurse plan to take?
Replace the external urinary catheter once each day.
Insert the catheter into the client's urethra.
Apply a barrier cream to the client's perineal skin.
Connect the catheter to continuous wall suction.
The Correct Answer is C
Choice A rationale
Replacing the external urinary catheter once each day is unnecessary. The catheter should be changed based on clinical judgment and manufacturer's guidelines to maintain hygiene.
Choice B rationale
Inserting the catheter into the client's urethra is incorrect for an external urinary catheter. External catheters are designed to be placed outside the body.
Choice C rationale
Applying a barrier cream to the client's perineal skin is correct. Barrier creams protect the skin from moisture and prevent skin breakdown and irritation caused by urine.
Choice D rationale
Connecting the catheter to continuous wall suction is not appropriate. External urinary catheters should be connected to a drainage bag for proper urine collection. .
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Correct Answer is B
Explanation
Choice A rationale
Placing the client into a right lateral position is not the standard position for administering an enema. The left lateral (Sims') position is commonly used as it facilitates the flow of the
solution into the colon.
Choice B rationale
Warming the enema solution to room temperature helps ensure the client's comfort and can prevent cramping and discomfort. Cold solutions can cause discomfort and cramping,
making the procedure less tolerable for the client.
Choice C rationale
Sterile technique is not required for administering an enema. Clean technique is generally sufficient unless otherwise indicated by the client’s condition or specific medical orders.
Choice D rationale
Lubricating the tubing is essential to ensure smooth insertion and prevent trauma to the rectal mucosa, but an oil-based lubricant is not typically used as it can interfere with the
absorption of the enema solution. Water-soluble lubricants are preferred.
Correct Answer is D
Explanation
Choice A rationale
Aging usually leads to a decrease in muscle tone of the bowel rather than an increase, which can result in slower bowel movements and constipation.
Choice B rationale
Gastric acid production tends to decrease with age, not increase. This can affect the digestion and absorption of nutrients, and also increase the risk of stomach infections.
Choice C rationale
The pH of the stomach tends to become less acidic (increase) as one ages, not decrease. This is often due to the reduced production of gastric acid.
Choice D rationale
Decreased intestinal peristalsis is a common physiological change in older adults. This slowing down of the intestinal movements can lead to constipation and other digestive issues.