The nurse is caring for a client with an indwelling catheter. Which of the following is an appropriate reason for assessing the urethral meatus?

To determine bladder fullness or distention.

To assess for skin breakdown or irritation.

To ensure and confirm catheter balloon inflation.

To closely monitor the client's urinary output.

Answer and Explanation

The Correct Answer is B

Rationale:
A. Determining bladder fullness or distention is not assessed through the urethral meatus. Nurses typically use palpation of the lower abdomen or a bladder scanner to evaluate bladder volume. The urethral meatus does not provide information about how full the bladder is or whether the client is retaining urine.

B. Assessing the urethral meatus is appropriate for evaluating skin integrity, irritation, redness, swelling, or signs of infection. Indwelling catheters increase the risk of trauma to the urethra and can introduce bacteria that lead to urethritis or urinary tract infections. Visual inspection allows the nurse to detect early complications, such as redness, discharge, swelling, or ulceration around the meatus. Timely identification of these issues enables interventions like catheter care, repositioning, or notifying the healthcare provider for treatment, reducing the risk of further injury or infection.

C. Ensuring and confirming catheter balloon inflation is done through the catheter’s inflation port, usually by verifying that the correct volume of sterile water has been instilled and the balloon is secure. The urethral meatus cannot reliably indicate whether the balloon is inflated or deflated, so visual inspection of the meatus is not a method for confirming balloon status.

D. Monitoring urinary output focuses on measuring the volume and characteristics of urine collected in the drainage bag, noting color, clarity, and any sediment. Observing the urethral meatus does not provide information about the amount of urine being produced or drained, so it is not used for this purpose.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:
A. A flow rate of 4 liters per minute is within the safe range for a nasal cannula but is not the maximum recommended rate. While some clients may require this flow, higher flow rates are possible and safe under certain conditions.

B. A flow rate of 6 liters per minute is the maximum flow rate typically recommended for a standard nasal cannula. Exceeding this rate can cause drying of the nasal mucosa, discomfort, and reduced effectiveness of oxygen delivery. Flow rates above 6 liters per minute generally require the use of a different delivery device, such as a simple face mask or high-flow oxygen system, to maintain safety and adequate oxygenation.

C. A flow rate of 8 liters per minute is too high for a standard nasal cannula and can cause nasal irritation, drying, and discomfort. It may also be less effective because the client may inhale room air that dilutes the oxygen.

D. A flow rate of 2 liters per minute is safe and commonly used for clients needing low-level supplemental oxygen, but it is not the maximum allowable flow rate for a nasal cannula.

A. Address client questions about medications after administration. B. Crush all medications for the client who has difficulty swallowing. C. Perform medication calculations to verify the correct dosages. D. Scan the prescribed medications before entering the client's room.

Correct Answer is C

Explanation

Rationale:
A. Addressing client questions about medications after administration is not ideal because clients may need information before taking their medications to ensure understanding, adherence, and informed consent.

B. Crushing all medications for a client with difficulty swallowing is unsafe. Some medications are extended-release, enteric-coated, or otherwise formulated to prevent irritation or ensure proper absorption. Crushing these can alter their effectiveness or cause harm. Medications should only be crushed if verified as safe by a pharmacist or prescriber.

C. Performing medication calculations to verify the correct dosages is the correct action. Older adults are at higher risk for adverse drug events due to age-related changes in metabolism, renal and hepatic function, and polypharmacy. Accurate calculation ensures the client receives the correct dose, preventing toxicity or subtherapeutic effects.

D. Scanning prescribed medications before entering the client’s room is a helpful safety step for barcode-assisted medication administration, but it is not specifically focused on the older adult population or on verifying dose accuracy. It complements but does not replace careful dose calculation and assessment.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for a client with an indwelling catheter. Which of the following is an appropriate reason for assessing the urethral meatus?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the maximum flow rate that can be set for a client who requires supplemental oxygen via a nasal cannula?

Correct Answer is B

Explanation

A nurse is preparing to administer medications to an older adult client. What action should the nurse plan to include in the client's care plan?

Correct Answer is C

Explanation

A nurse is preparing to administer medications to a client. What priority action should the nurse take to protect the client from being given the wrong medication?

The nurse evaluates a client after removing their indwelling urinary catheter. For each assessment finding, click to specify whether the finding is expected or unexpected.

A nurse provides education to a client on buccal medication. Which statement by the client indicates effective learning?

Match the type of parenteral injection to its appropriate injection site. Types of Parenteral Injections Injection sites Intramuscular injection Intradermal injection Subcutaneous injection Intravenous injection dropdown dropdown dropdown dropdown

Which identifier(s) may be used in diverse healthcare settings? Select all that apply.

The nurse cares for a client on total parenteral nutrition. What action should the nurse take to prevent complications associated with parenteral nutrition?

What is the nurse's priority question before feeding a client for the first time?

Which equipment is necessary to perform tracheostomy care on a client? Select all that apply.