A nurse is reinforcing discharge teaching with a male client who has an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?

"I will empty my drainage bag once a day."

"I will keep the drainage bag below the level of my waist."

"I will apply antiseptic ointment to the tip of my penis."

"I will clamp the tube when I go for a walk."

Answer and Explanation

The Correct Answer is B

A. "I will empty my drainage bag once a day.": The bag should be emptied when it is half to two-thirds full, or at least every 8 hours, to prevent tension and bacterial growth.

B. "I will keep the drainage bag below the level of my waist.": Keeping the bag lower than the bladder ensures that gravity allows urine to flow out and prevents the backflow (reflux) of contaminated urine into the bladder.

C. "I will apply antiseptic ointment to the tip of my penis.": Routine use of antiseptic ointments at the meatus is not recommended and can actually increase the risk of infection by trapping bacteria.

D. "I will clamp the tube when I go for a walk.": The catheter should never be clamped without a specific medical order, as it causes urine to back up into the bladder and kidneys.

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Correct Answer is C

Explanation

A. "Don't worry. Everything will work out for you.": This provides false reassurance and dismisses the client's feelings.

B. "We should talk about your decision later.": This is avoidant and dismisses the client's current need for support.

C. "How will you discuss this decision with your loved ones?": This is an open-ended, therapeutic response that encourages the client to explore their support system and the implications of their decision.

D. "Your quality of life will be compromised if you make this decision.": This is judgmental and uses a "scare tactic" rather than supporting the client's autonomy.

A. The stoma appears dark in color. B. The stoma bleeds lightly when touched. C. The stoma is draining a small amount of liquid stool. D. The stoma protrudes slightly from the abdomen.

Correct Answer is A

Explanation

A. The stoma appears dark in color.: A healthy stoma should be moist and reddish-pink. A dark (purple, black, or dusky) stoma indicates ischemia or poor perfusion and must be reported immediately to prevent tissue death.

B. The stoma bleeds lightly when touched.: This is a common and expected finding, as stoma tissue is highly vascular and fragile, especially in the early postoperative period.

C. The stoma is draining a small amount of liquid stool.: This is an expected finding 2 days postoperatively as the bowel begins to resume function.

D. The stoma protrudes slightly from the abdomen.: A slight protrusion (budding) is normal and helps the stool fall into the collection pouch rather than sitting on the skin.

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A nurse is reinforcing discharge teaching with a male client who has an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?

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