The nurse is inserting an indwelling urinary catheter for a male client. As the catheter is inserted into the
urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon?
Insert the catheter 2-5 cm and then inflate the balloon.
Immediately inflate the balloon as soon as urine return is noted.
Continue to advance the catheter to the bifurcation (Y level of port) and then inflate balloon.
Insert the catheter until resistance is met, slightly pull back the tubing and then inflate the balloon.
The Correct Answer is A
The correct answer is choice A. After inserting the catheter 2-5 cm, the nurse should then inflate the balloon. It is important to confirm urine return before inflating the balloon to ensure that the catheter is in the correct position and has not entered the bladder neck or prostate. Inflating the balloon before confirming urine return can cause trauma and increase the risk of infection. Option B is incorrect because inflating the balloon too early can cause discomfort, trauma and increase the risk of infection. Option C is incorrect because advancing the catheter too far can cause injury to the bladder or ureters. Option D is incorrect because pulling back the catheter after meeting resistance can also cause trauma to the urethra.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D, Evaluation.
Evaluation is the step of the nursing process where the nurse assesses the client's response to interventions that were implemented during the implementation step. In this scenario, the nurse administered pain medication and is now evaluating its effectiveness by asking the client to rate their current level of pain on a scale of 0 to 10. Based on the client's response, the nurse can determine whether the intervention was successful or whether adjustments to the plan of care are necessary.
Correct Answer is D
Explanation
The correct answer is choice D, Jell-O, broth, apple juice. A clear liquid diet consists of fluids and foods that are clear and liquid at room temperature. These foods are easy to digest and leave no residue in the gastrointestinal tract. Examples include water, clear fruit juices, clear broths, tea, coffee without cream, and Jell-O.
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