A nurse is providing discharge instructions about clean intermittent self-catheterization to a patient who has benign prostatic hyperplasia.
Which of the following instructions should the nurse include?
“Use soap and water to clean the catheter after each use.”.
“Hold the penis at a 30 to 45-degree angle when inserting the catheter.”.
“Perform catheterization when you feel the urge to void.”.
“Inflate the balloon when the urine flow stops.”.
The Correct Answer is A
Choice A rationale
Cleaning the catheter after each use with soap and water is a crucial step in preventing infection during self-catheterization.
Choice B rationale
The angle at which the penis should be held during catheter insertion can vary, but a 30 to 45- degree angle is not typically recommended.
Choice C rationale
Performing catheterization when feeling the urge to void is not typically part of the instructions for clean intermittent self-catheterization.
Choice D rationale
Inflating the balloon when the urine flow stops is not a step in clean intermittent self- catheterization. This step is associated with indwelling catheters, not intermittent catheters.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The priority action for a nurse when caring for a patient exhibiting symptoms of a myocardial infarction is to initiate oxygen therapy. Oxygen therapy is crucial because it increases the amount of oxygen in the blood, which can help reduce the heart’s workload and relieve pain. This intervention is aimed at reducing myocardial oxygen demand and improving oxygen supply to the ischemic myocardium.
Choice B rationale
Obtaining a blood sample is important as it can help diagnose a myocardial infarction. Blood tests can measure levels of certain proteins, such as troponins, in the bloodstream that can indicate heart muscle damage. However, this is not the immediate priority when compared to initiating oxygen therapy.
Choice C rationale
Attaching the leads for a 12-lead ECG is an important step in the assessment of a patient with suspected myocardial infarction. An ECG can show whether the heart muscle has been damaged and where the damage has occurred. However, this should be done after initiating oxygen therapy.
Choice D rationale
Inserting an IV catheter is a necessary step in the management of a myocardial infarction. It allows for the administration of medications and fluids as needed. However, it is not the first priority. The first priority is to stabilize the patient, which includes initiating oxygen therapy.
Correct Answer is A
Explanation
Choice A rationale
The statement “Our car seat is an infant model and is anchored in the car” indicates a correct understanding of car seat safety. Infant car seats are specifically designed to protect infants during a collision. They are rear-facing seats, which is the safest position for an infant because it provides the most support for the infant’s head, neck, and spine. Anchoring the car seat in the car is crucial as it ensures the seat stays in place during a collision.
Choice B rationale
The statement “The car seat is rear-facing in the front passenger seat” is incorrect. It is not safe to place a rear-facing car seat in the front passenger seat of a vehicle. In the event of a collision, an airbag can deploy and hit the car seat, causing serious injury to the infant.
Choice C rationale
The statement “I can fit my hand between the baby and the car seat harness” is incorrect. The harness of a car seat should be snug against the baby’s body. If you can fit your hand between the baby and the harness, it means the harness is too loose, which can be dangerous in the event of a collision.
Choice D rationale
The statement “Our car seat is front-facing in the back seat” is incorrect. Infants should always be in a rear-facing car seat until they reach the highest weight or height allowed by their car safety seat’s manufacturer.
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