A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has benign prostatic hyperplasia. Which of the following instructions should the nurse include?

Hold the penis at a 30° to 45° angle when inserting the catheter.

Perform catheterization when you recognize the urge to void.

Use soap and water to wash the catheter after each use.

Inflate the balloon when the urine flow stops.

Answer and Explanation

The Correct Answer is C

A. Hold the penis at a 30° to 45° angle when inserting the catheter. The penis should be held at a 90° angle to straighten the urethra and facilitate catheter insertion.

B. Perform catheterization when you recognize the urge to void. Clients with BPH may not sense the urge due to urinary retention. Catheterization should be performed at scheduled intervals to prevent bladder overdistention.

C. Use soap and water to wash the catheter after each use. Proper cleaning of the catheter with soap and water helps prevent infection and prolongs the catheter’s usability.

D. Inflate the balloon when the urine flow stops. Self-catheterization uses a straight catheter, which does not have a balloon for inflation (balloons are used in indwelling catheters).

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Correct Answer is A

Explanation

A. Stoma is purple. A purple, dusky, or black stoma indicates poor blood circulation, possibly due to ischemia or necrosis. This is a surgical emergency requiring immediate attention.

B. Stoma is moist. Normal finding, indicating adequate perfusion.

C. Stoma is flush with the skin. Possible but not necessarily abnormal. However, a retracted stoma (sunken below skin level) could lead to leakage and skin irritation.

D. Stoma is protruding from the abdomen. Normal in the early postoperative period. A slight protrusion (bud-like shape) is expected. However, significant prolapse (excessive protrusion) may need evaluation.

Correct Answer is ["740"]

Explanation

4 oz juice → 120 mL
6 oz tea → 180 mL
100 mL ice chips → 50 mL (Ice chips are counted as half their volume when melted)
IV bolus → 150 mL
8 oz broth → 240 mL

Total intake:

120+180+50+150+240=740mL120 + 180 + 50 + 150 + 240=740mL

Correct answer: 740 mL

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A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has benign prostatic hyperplasia. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately?

Correct Answer is A

Explanation

A nurse is completing an 8-hr 1&0 record for a client who consumed 4 oz juice, 6 oz tea, a 100 mL cup full of ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client's record?

Correct Answer is ["740"]

Explanation

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