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 A
Explanation
Correct Answer is D
Explanation
A.Taping the tube to the child's cheek is not a recommended practice. It can cause skin irritation, discomfort, or even accidental removal of the tube. Proper securing of the tube to the abdomen using appropriate devices is the preferred method to prevent dislodgement.
B.Applying lubricant to the site is not necessary or recommended. The gastrostomy tube should be kept clean and dry. If any secretions or debris are present, they should be gently cleaned with mild soap and water, followed by thorough rinsing and drying.
C.Some gastrostomy tubes require an extension set for feeding, especially low-profile devices (e.g., button-type gastrostomy tubes). This extension makes it easier to administer feeds or medications and can be removed afterward. However, this is not typically part of routine site care.
D.Securing the tubing to the child's abdomen helps prevent accidental dislodgement or pulling of the gastrostomy tube. This can be done using appropriate securing devices, such as adhesive dressings or commercially available tube holders, as recommended by the healthcare provider.
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