A nurse is preparing to apply a condom catheter for a client who is uncircumcised. Which of the following actions should the nurse plan to take?
Keep foreskin in a retracted position after application of the catheter.
Allow 2.5 to 5 cm (1 to 2 in) between the end of the catheter and the tip of the penis.
Place adhesive tape directly on the penis.
Change the condom catheter every 3 days.
The Correct Answer is A
A condom catheter is a urine collection device that fits like a condom over the penis and has a tube that goes to a collection bag strapped to the leg. To apply a condom catheter, the nurse should clean and dry the penis thoroughly, unroll the sheath over the penis, leaving 2.5 to 5 cm (1 to 2 in) of space between the end of the catheter and the tip of the penis, and gently squeeze the catheter around the penis shaft for 10 to 15 seconds to ensure adhesion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
The nurse should assess the client's vital signs first to determine if there are any signs of fluid overload, such as hypertension, edema, crackles, or dyspnea. The nurse should then notify the primary care provider.
Correct Answer is A
Explanation
Cheyne-Stokes respirations are an abnormal pattern of breathing characterized by progressively deeper, and sometimes faster, breathing followed by a gradual decrease that results in a temporary stop in breathing called an apnea. The pattern repeats, with each cycle usually taking 30 seconds to 2 minutes. This type of breathing may occur in people who are dying due to heart failure, stroke, brain injury or other causes. The nurse should expect to observe irregular respirations with frequent periods of apnea in the client who is dying and having Cheyne-Stokes respirations.
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