A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has benign prostatic hyperplasia. Which of the following instructions should the nurse include?

Hold the penis at a 30° to 45° angle when inserting the catheter.

Perform catheterization when you recognize the urge to void.

Use soap and water to wash the catheter after each use.

Inflate the balloon when the urine flow stops.

Answer and Explanation

The Correct Answer is C

A. Hold the penis at a 30° to 45° angle when inserting the catheter. The penis should be held at a 90° angle to straighten the urethra and facilitate catheter insertion.

B. Perform catheterization when you recognize the urge to void. Clients with BPH may not sense the urge due to urinary retention. Catheterization should be performed at scheduled intervals to prevent bladder overdistention.

C. Use soap and water to wash the catheter after each use. Proper cleaning of the catheter with soap and water helps prevent infection and prolongs the catheter’s usability.

D. Inflate the balloon when the urine flow stops. Self-catheterization uses a straight catheter, which does not have a balloon for inflation (balloons are used in indwelling catheters).

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Correct Answer is D

Explanation

A. After the client feels abdominal cramping: Too late. Cramping may indicate constipation or excessive straining.

B. Immediately before the client has a meal: Not effective. The gastrocolic reflex occurs after eating, not before.

C. Every 2 hr while the client is awake: This is unnecessary and does not align with the body’s natural elimination pattern.

D. When the client has the urge to defecate: Most effective approach. Encourages natural elimination patterns.

A. Measure bladder with had of bed raised to 60 degrees. B. Measure bladder with head of bed raised to 90 degrees. C. Measure bladder within 15 minutes after the patient voids D. Measure bladder before the patient voids.

Correct Answer is C

Explanation

A. Measure bladder with the head of the bed raised to 60 degrees. The patient should be in the supine position for the most accurate measurement.

B. Measure bladder with the head of the bed raised to 90 degrees. The patient should be in a flat or slightly reclined position for bladder scanning.

C. Measure bladder within 15 minutes after the patient voids. Postvoid residual (PVR) is the amount of urine left in the bladder after urination. It should be measured within 15 minutes of voiding for accuracy.

D. Measure bladder before the patient voids. Measuring before voiding does not assess residual urine, which is the purpose of the test.

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A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has benign prostatic hyperplasia. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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