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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Sitting in high-Fowler's position during the feeding is actually a preventive measure against aspiration. High-Fowler's position, which involves sitting the patient upright at a 90-degree angle, reduces the risk of aspiration by promoting proper digestion and preventing the regurgitation of gastric contents into the lungs.
Choice B rationale:
A history of gastroesophageal reflux disease (GERD) puts the client at risk for aspiration. GERD is a chronic condition in which stomach acid frequently flows back into the esophagus, potentially reaching the throat and lungs, increasing the risk of aspiration during enteral feedings. Aspiration pneumonia, a serious complication, can develop if stomach contents enter the lungs.
Choice C rationale:
A residual of 65 mL 1 hr postprandial indicates that a significant amount of the feeding solution has not been absorbed, raising concerns about delayed gastric emptying. While this situation might require monitoring and adjustments to the feeding regimen, it does not directly increase the risk of aspiration. Aspiration risk is more related to the reflux of stomach contents into the airways.
Choice D rationale:
Receiving a high-osmolarity formula alone does not directly increase the risk of aspiration. High-osmolarity formulas might require careful administration and monitoring to prevent complications, but aspiration risk is more closely associated with the client's underlying conditions, such as GERD.
Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A,B"}}
No explanation
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