Which action should the nurse implement when inserting an indwelling catheter for an uncircumcised male client?

Clean the urinary meatus before retracting the foreskin.

Position the sterile field even with the nurse's hips.

Use a swab to wipe the meatus in back-and-forth motions.

Advance the catheter before inflating the balloon.

Answer and Explanation

The Correct Answer is A

A. Clean the urinary meatus before retracting the foreskin is the correct action. Before retracting the foreskin, the nurse should clean the meatus to prevent contamination of the catheterization site. This ensures that any bacteria present are removed before inserting the catheter.

B. Position the sterile field even with the nurse's hips is not directly related to the procedure for an uncircumcised male client. The sterile field should be positioned at a level where the nurse can comfortably reach it without contaminating it, but this does not specifically address the care of an uncircumcised male.

C. Use a swab to wipe the meatus in back-and-forth motions is incorrect. The meatus should be cleaned using a circular motion, starting at the meatus and working outward. Back-and-forth motions could cause contamination of the area.

D. Advance the catheter before inflating the balloon is an appropriate action during catheter insertion; however, this is not specific to the care of an uncircumcised male client. The balloon should be inflated only after the catheter is fully inserted and urine flow is confirmed.

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Correct Answer is C

Explanation

A. Explain that alternative treatment options may be helpful is not appropriate at this moment. The spouse is expressing grief, and the focus should be on emotional support rather than discussing medical treatment options, which may not be relevant to the spouse’s current emotional state.

B. Offer reassurance that the spouse is not alone may provide some comfort but does not address the underlying need for the spouse to express their emotions. It is more important to listen and allow the spouse to share their feelings first.

C. Encourage the spouse to share their feelings is the most appropriate first response. The spouse is expressing emotional distress, and the nurse should offer a safe space for the spouse to talk about their feelings. This approach helps to validate the spouse’s emotions and provides an opportunity for emotional support.

D. Remind the spouse that the client may still live a long time is not appropriate because it could invalidate the spouse’s feelings of loss and grief. The spouse is dealing with the reality of the terminal illness, and the nurse should not offer false hope or minimize the situation.

A. Verify client's identification by scanning the barcode on the armband. B. Reconcile the medication to be administered with the initial client prescription. C. Remove the medication from the unit dose packaging while verifying the dose. D. Scan the medication barcode to document administration on the eMAR.

Correct Answer is A

Explanation

A. Verify client's identification by scanning the barcode on the armband is correct because verifying the client’s identity is the next step after accessing the eMAR. This ensures that the right medication is given to the right client, following the “rights” of medication administration.

B. Reconcile the medication to be administered with the initial client prescription is important but should already have been completed during the medication preparation and verification process.

C. Remove the medication from the unit dose packaging while verifying the dose is part of the preparation process but occurs after confirming the client’s identity.

D. Scan the medication barcode to document administration on the eMAR is done after verifying the client’s identity and ensuring the medication is correct. It is not the immediate next step after logging into the eMAR.

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Which action should the nurse implement when inserting an indwelling catheter for an uncircumcised male client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

Correct Answer is C

Explanation

When administering a new medication to a client, the nurse logs in the electronic medication administration record (eMAR). Which action should the nurse take next?

Correct Answer is A

Explanation

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