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. The grounding pad is positioned near the surgical site.: The grounding pad (for electrocautery) should be placed over a large, well-vascularized muscle mass, away from the surgical site and bony prominences.

B. The client's surgical site is shaved with a razor.: Razors create "micro-cuts" that increase the risk of surgical site infections. Clippers are preferred if hair removal is necessary.

C. The client is positioned to minimize pressure on the skin.: During surgery, clients are unable to move or feel pain. Proper padding and positioning are essential to prevent pressure injuries and nerve damage.

D. The client is covered with a cooling blanket.: Maintaining normothermia (normal body temperature) is critical for healing and preventing infection; warming blankets are typically used.

A. Check for a positive Babinski reflex. B. Have the client perform heel-to-toe walking. C. Perform the Romberg test. D. Have the client lie in bed and use his heel to draw a line on the opposite shin. E. Perform Weber's test.

Correct Answer is ["B","C"]

Explanation

A. Check for a positive Babinski reflex.: This is used to assess upper motor neuron dysfunction, not balance.

B. Have the client perform heel-to-toe walking.: This (tandem walking) tests cerebellar function and the client's ability to maintain an upright posture while moving.

C. Perform the Romberg test.: The Romberg test assesses balance by having the client stand with feet together and eyes closed; significant swaying indicates a loss of balance.

D. Have the client lie in bed and use his heel to draw a line on the opposite shin.: This (heel-to-shin test) assesses coordination, but since the client is lying down, it does not test balance.

E. Perform Weber's test.: This is a hearing test used to determine if sound is heard equally in both ears.

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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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Naxlex Comprehensive Predictor Exams

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