A nurse is inserting an indwelling urinary catheter for a male client.
Which of the following actions should the nurse take?
Lift the penis so that it is perpendicular to the client's body.
Cleanse the tip of the penis in a side-to-side motion.
Pick up the catheter 13 cm (5 in) from its tip.
Inflate the catheter balloon before insertion.
The Correct Answer is A
The correct answer is choice A. Lift the penis so that it is perpendicular to the client’s body.
Choice A rationale:
Lifting the penis so that it is perpendicular to the client’s body straightens the urethra, making it easier to insert the catheter without causing trauma.
Choice B rationale:
While cleansing the tip of the penis in a circular motion is important for maintaining aseptic technique, it is not the specific action that facilitates the insertion of the catheter.
Choice C rationale:
Picking up the catheter 13 cm (5 in) from its tip is not a standard practice. The nurse should hold the catheter closer to the tip to maintain control and ensure accurate insertion.
Choice D rationale:
Inflating the catheter balloon before insertion can cause trauma to the urethra and is not recommended. The balloon should only be inflated once the catheter is correctly positioned in the bladder.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Choosing an agency to provide home physical therapy is important, but it is not the priority in this situation. The client's safety and immediate needs should be addressed first.
Choice B rationale:
Obtaining an alert system to get help in case of a fall is the priority for an older adult living alone with left-sided weakness following a stroke. Falls can result in serious injuries, so having an alert system ensures the client can call for assistance promptly, enhancing their safety and well-being.
Choice C rationale:
Providing information about available transportation resources is important for the client's long-term independence and quality of life. However, immediate safety concerns, such as the risk of falls, should be addressed first.
Choice D rationale:
Reviewing information about support groups for individuals who have had a stroke is essential for the client's emotional well-being and social support. However, immediate safety measures, such as fall prevention, take precedence in this scenario.
Correct Answer is B
Explanation
The correct answer is B.
Choice A reason: Avoid preparing medications for more than two clients at one time is a guideline aimed at reducing the risk of medication errors. However, it is not an absolute rule and may vary depending on the setting and resources available.
Choice B reason: Inform clients about the action of each medication prior to administration. This practice is essential for patient education, ensuring that patients are informed about what medications they are taking and why, which can improve adherence and outcomes.
Choice C reason: Reading medication labels at least two times prior to administration is a good practice to avoid errors, but it is not always specified as a standard requirement in medication administration guidelines.
Choice D reason: Completing an incident report if a client vomits after taking a medication is necessary only if the vomiting is related to an adverse drug reaction or a medication error, not for routine vomiting.
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