A nurse is inserting an indwelling urinary catheter for a male client.
Which of the following actions should the nurse take?

Lift the penis so that it is perpendicular to the client's body.

Cleanse the tip of the penis in a side-to-side motion.

Pick up the catheter 13 cm (5 in) from its tip.

Inflate the catheter balloon before insertion.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. Lift the penis so that it is perpendicular to the client’s body.

Choice A rationale:

Lifting the penis so that it is perpendicular to the client’s body straightens the urethra, making it easier to insert the catheter without causing trauma.

Choice B rationale:

While cleansing the tip of the penis in a circular motion is important for maintaining aseptic technique, it is not the specific action that facilitates the insertion of the catheter.

Choice C rationale:

Picking up the catheter 13 cm (5 in) from its tip is not a standard practice. The nurse should hold the catheter closer to the tip to maintain control and ensure accurate insertion.

Choice D rationale:

Inflating the catheter balloon before insertion can cause trauma to the urethra and is not recommended. The balloon should only be inflated once the catheter is correctly positioned in the bladder.

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Correct Answer is D

Explanation

A. A client who has epidural analgesia and weakness in the lower extremities. B. A client who has diabetes mellitus and an HbA1c of 6.89%. C. A client who has a hip fracture and a new onset of tachypnea. D. A client who has sinus arrhythmia and is receiving cardiac monitoring.

Correct Answer is C

Explanation

Choice A rationale:

The client with epidural analgesia and weakness in the lower extremities might be experiencing complications related to the epidural, such as epidural hematoma or nerve damage. However, the immediate concern is the client with a hip fracture and new onset of tachypnea. Tachypnea can indicate a pulmonary embolism or worsening respiratory status due to the fracture, both of which require urgent assessment and intervention.

Choice B rationale:

The client with diabetes mellitus and an HbA1c of 6.89% has a well-controlled blood glucose level. This condition does not require immediate attention compared to the client with a hip fracture and tachypnea, who might be experiencing a life-threatening complication.

Choice C rationale:

The client with a hip fracture and new onset of tachypnea is the priority for assessment. Tachypnea can be a sign of respiratory distress, which could indicate a pulmonary embolism or worsening lung function due to the fracture. Timely intervention is crucial to prevent further complications.

Choice D rationale:

The client with sinus arrhythmia and cardiac monitoring is stable and does not require immediate attention compared to the client with a hip fracture and tachypnea.

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A nurse is inserting an indwelling urinary catheter for a male client.
Which of the following actions should the nurse take?