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 C

Explanation

Choice A rationale:

Allowing the client to have time alone in their room might provide some relief, but it does not address the caregiver's overall stress and the impact on their life. Moreover, constant isolation is not a healthy solution for the client, as social interaction is essential for their well-being.

Choice B rationale:

Discussing methods of communication with the client about resolving problem behaviors is a helpful approach. Effective communication strategies can reduce misunderstandings and challenging behaviors, easing the burden on the caregiver. This choice demonstrates a proactive approach to improving the caregiver's situation.

Choice C rationale:

Assisting the caregiver in arranging for a daycare program for the client is an excellent solution. Adult daycare programs provide a safe and stimulating environment for individuals with Alzheimer's disease, allowing caregivers to have some respite while ensuring the well-being of their loved ones. This choice addresses both the client's needs and the caregiver's stress, making it the most appropriate option.

Choice D rationale:

Suggesting that the caregiver seek a prescription for an antipsychotic medication for the client is not the best course of action without a thorough evaluation by a healthcare provider. Antipsychotic medications have side effects and are typically prescribed based on the client's specific symptoms and needs. Additionally, prescribing medications is beyond the nurse's scope of practice and should be determined by a healthcare provider after a comprehensive assessment.

A. Eat a meal. B. Take pancrelipase. C. Use an albuterol inhaler. D. Complete oral hygiene.

Correct Answer is C

Explanation

The correct answer is c. Use an albuterol inhaler.

Choice A reason: Eating a meal before postural drainage is not recommended because it can cause discomfort, nausea, or vomiting due to the positions required for the procedure.

Choice B reason: Taking pancrelipase is important for aiding digestion in cystic fibrosis patients, but it is not specifically related to the preparation for postural drainage.

Choice C reason: Bronchodilators like albuterol are used before airway clearance techniques to open the airways, making it easier to clear mucus during postural drainage.

Choice D reason: While maintaining oral hygiene is important for overall health, it is not a preparation step for postural drainage.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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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?