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 B

Explanation

The correct answer is **b. A room containing personal belongings.**

Choice A rationale:

A room without a window would not be a therapeutic environment for a cognitively impaired client. Lack of natural light and connection to the outside world can be disorienting and distressing for these patients.

Choice B rationale:

A room containing personal belongings is the most therapeutic environment for a cognitively impaired client. Familiar objects and surroundings can help provide a sense of comfort, security, and orientation. This can reduce agitation and confusion, which are common issues for cognitively impaired patients.

Choice C rationale:

A room adjacent to the nursing station may not be the most therapeutic environment. While proximity to staff can be beneficial, the increased noise and activity level near the nursing station could be overstimulating and disruptive for a cognitively impaired client.

Choice D rationale:

A room with dim lighting is not ideal for a cognitively impaired client. Adequate lighting is important to help these patients maintain orientation and avoid falls or other safety issues. Dim lighting can contribute to confusion and disorientation.

A. Provide a verbal report of the client's condition to the paramedic performing the transfer. B. Fax the client's name and identifiable information to the rehabilitation facility. C. Email the client's health information to the facility in an unencrypted file. D. Discuss the client's response to the transfer with another staff nurse.

Correct Answer is A

Explanation

Choice A rationale:

Providing a verbal report of the client's condition to the paramedic performing the transfer violates the client's confidentiality. Protected health information should not be disclosed verbally to individuals who do not have a need to know. Confidentiality must be maintained during all stages of care, including transfers.

Choice B rationale:

Faxing the client's name and identifiable information to the rehabilitation facility is not a secure method of transmitting sensitive health information. Faxed documents can be intercepted, compromising the client's confidentiality. Secure electronic methods or encrypted communication should be used for transmitting such information.

Choice C rationale:

Emailing the client's health information to the facility in an unencrypted file is also insecure and violates the client's confidentiality. Unencrypted emails can be intercepted and read by unauthorized individuals. Protected health information should be transmitted using secure, encrypted methods to maintain confidentiality.

Choice D rationale:

Discussing the client's response to the transfer with another staff nurse is inappropriate and breaches confidentiality. Sharing patient information, even within the healthcare team, should only be done on a need-to-know basis and in a secure, private setting.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is taking care of a client who is cognitively impaired. The nurse recognizes that which of the following rooms will provide a therapeutic environment for this client?

Correct Answer is B

Explanation

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Explanation

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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?