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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Acetone breath is a symptom of diabetic ketoacidosis (DKA), a complication of diabetes mellitus. It occurs due to the presence of ketones in the breath and is not specific to hypoglycemia. Hypoglycemia is characterized by low blood sugar levels, not elevated ketone levels.
Choice B rationale:
Confusion is a common symptom of hypoglycemia. When blood sugar levels drop significantly, the brain may not receive enough glucose to function properly, leading to confusion, dizziness, and other neurological symptoms.
Choice C rationale:
Polydipsia refers to excessive thirst and is a symptom of hyperglycemia (high blood sugar levels), not hypoglycemia. In hyperglycemic states, the body tries to eliminate excess glucose through urine, leading to increased thirst.
Choice D rationale:
Hot, dry skin is not a typical symptom of hypoglycemia. Hypoglycemia can cause diaphoresis (excessive sweating) and cool, clammy skin due to the body's stress response.
Correct Answer is B
Explanation
An advance directive is a legal document that allows a client to express their wishes regarding medical care in case they become incapacitated. The client should discuss this document with their family before signing it, so that they are aware of the client's preferences and can respect them. The other options are incorrect because the client can change their mind at any time, their partner does not need to be present, and an attorney does not need to notarize the document.
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