A nurse is caring for a male patient experiencing urinary retention. Which action should the nurse take first?

Limit fluid intake.

Insert a urinary catheter.

Assist to a standing position.

Ask for a diuretic medication.

Answer and Explanation

The Correct Answer is C

A. Limit fluid intake:
This can worsen retention by reducing the urge to void. Not appropriate unless fluid overload is present.

B. Insert a urinary catheter:
This may be required, but non-invasive interventions like position change should be tried first, especially if there's no acute distress.

C. Assist to a standing position:
For male patients, standing often promotes natural voiding by utilizing gravity and familiarity of position. Least invasive and most appropriate initial step.

D. Ask for a diuretic medication:
Diuretics increase urine production but do not resolve urinary retention. They may worsen bladder distention.

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Correct Answer is D

Explanation

A. Hold the shaft of the penis at a 60-degree angle:
The penis should be held at a 90-degree angle (perpendicular to the body) to straighten the urethra and ease catheter insertion.

B. Hold the shaft of the penis with the dominant hand:
The non-dominant hand is used to hold the penis and is considered contaminated after touching the patient. The dominant hand inserts the catheter using sterile technique.

C. Cleanse the meatus 3 times with the same cotton ball from clean to dirty:
A new cotton ball or swab should be used each time to prevent contamination. "Clean to dirty" implies incorrect direction-meatus is the cleanest part.

D. Cleanse the meatus with circular strokes beginning at the meatus and working outward:
This is the correct technique for male catheterization. Start at the urethral opening and clean outward using sterile technique.

A. Emptying the drainage bag when half full B. Kinking the catheter tubing to obtain a urine specimen C. Placing the drainage bag on the side rail of the patient's bed D. Securing the catheter tubing to the patient's thigh

Correct Answer is C

Explanation

A. Emptying the drainage bag when half full:
This helps prevent backflow and tension on the catheter. It is an appropriate action.

B. Kinking the catheter tubing to obtain a urine specimen:
While not ideal, temporary kinking (with care) may be done to collect a specimen. This is not the worst safety breach.

C. Placing the drainage bag on the side rail of the patient's bed:
The bag must be kept below bladder level to prevent reflux and infection. Side rails can move, leading to unsafe positioning.

D. Securing the catheter tubing to the patient's thigh:
Properly securing the catheter prevents traction and reduces the risk of injury or dislodgement.

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A nurse is caring for a male patient experiencing urinary retention. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is inserting an indwelling urinary catheter for a male patient. Which action will the nurse take??

Correct Answer is D

Explanation

A nurse is evaluating a nursing assistive personnel's (AP) care for a patient with an indwelling catheter. Which action by the AP will cause the nurse to intervene?

Correct Answer is C

Explanation

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