The nurse is inserting an indwelling urinary catheter for a male client. As the catheter is inserted into the
urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon?
Insert the catheter 2-5 cm and then inflate the balloon.
Immediately inflate the balloon as soon as urine return is noted.
Continue to advance the catheter to the bifurcation (Y level of port) and then inflate balloon.
Insert the catheter until resistance is met, slightly pull back the tubing and then inflate the balloon.
The Correct Answer is A
The correct answer is choice A. After inserting the catheter 2-5 cm, the nurse should then inflate the balloon. It is important to confirm urine return before inflating the balloon to ensure that the catheter is in the correct position and has not entered the bladder neck or prostate. Inflating the balloon before confirming urine return can cause trauma and increase the risk of infection. Option B is incorrect because inflating the balloon too early can cause discomfort, trauma and increase the risk of infection. Option C is incorrect because advancing the catheter too far can cause injury to the bladder or ureters. Option D is incorrect because pulling back the catheter after meeting resistance can also cause trauma to the urethra.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C: Listen with the stethoscope at the fifth intercostal space left mid clavicular line. This is the correct location to auscultate the apical pulse or apical heart rate. The apical pulse is the sound of the heart beating heard through a stethoscope placed over the apex of the heart, which is located at the fifth intercostal space at the left mid-clavicular line. The second intercostal space at the left sternum is the location to auscultate the aortic valve, while the fifth intercostal space at the sternum is the location to auscultate the tricuspid valve. The neck to the right of the coracoid process is not a location to auscultate the apical pulse.
Correct Answer is D
Explanation
The correct answer is choice D. Gather new sterile supplies and start the procedure over.
In order to maintain surgical asepsis during a urinary catheterization procedure, the nurse must ensure that all equipment used is sterile and that there is no contamination of the equipment during the procedure. If the catheter is contaminated, the nurse should stop the procedure, gather new sterile supplies, and start the procedure over to prevent the introduction of bacteria into the urinary tract. Reporting the incident and apologizing to the client are important, but not the first priority in maintaining surgical asepsis. The fact that the client is on antibiotics does not change the need for sterile technique during the procedure.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.