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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
In the context of an emergency response plan following an external disaster and the need to create bed space for potential admissions, the nurse should consider early discharge for clients who are stable and whose discharge will not compromise their safety or health. Based on the given options, the most appropriate candidate for early discharge would be:
B) A client who is 1 day postoperative following a vertebroplasty.
Clients who are one day postoperative after a vertebroplasty are typically recovering from a relatively minor procedure and may be stable for discharge if their condition remains uncomplicated.
The other options:
A) A client receiving heparin for deep-vein thrombosis may require ongoing monitoring and treatment, and early discharge might not be appropriate.
C) A client with cancer and a sealed implant for radiation therapy likely has specific treatment needs and should not be discharged early.
D) A client with COPD and a respiratory rate of 44/min likely has respiratory distress and should not be discharged early. Their condition requires close monitoring and intervention.
Correct Answer is D
Explanation
The correct answer is D.
Choice A reason: “A. Using this machine increases my risk of overdose.” This statement is incorrect because PCA pumps are designed with safety mechanisms to prevent overdose. The pump is programmed to deliver a specific dose of medication at set intervals, and it will not dispense more medication than what is prescribed by the healthcare provider.
Choice B reason: “B. I can get pain medication any time as long as I press the button.” While it is true that the patient can self-administer medication, PCA pumps have a lockout interval that prevents the machine from delivering another dose until a certain amount of time has passed, ensuring that the patient cannot receive medication too frequently.
Choice C reason: “C. My partner can press my pain medication button for me if I am sleeping.” This statement is incorrect. Only the patient should press the button on the PCA pump to ensure that the medication is administered safely and according to the patient’s current level of pain. Allowing someone else to press the button could lead to unsafe dosing.
Choice D reason: “D. I will receive a limited amount of pain medication when I press the button.” This is the correct statement. The PCA pump allows the patient to administer a controlled amount of pain medication within safe limits set by the healthcare provider. The pump is programmed to deliver a specific dose of medication, and there is a limit to the number of doses that can be administered per hour.
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