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 B
Explanation
The correct answer is choice B, safety measures necessary to prevent a fire. When teaching a home care client and their family about using prescribed oxygen, safety measures are critical. Oxygen supports combustion, so it is important to follow safety measures to prevent a fire. These safety measures include avoiding smoking, using electric razors instead of a blade, and avoiding flammable products such as oils, aerosol sprays, and alcohol-based hand sanitizers near the oxygen source. The oxygen should be kept away from heat sources and the tubing should be free from kinks or damage. The healthcare provider's phone number should also be readily available in case of any questions or emergencies.
Correct Answer is ["A","E"]
Explanation
Correct answers are:
A. Documenting an assessment that was not performed
E. The nurse documents blood labs were sent before the blood draw was performed
Falsification of health records refers to deliberately misrepresenting, fabricating, or altering documentation, which could lead to severe consequences for patients and healthcare providers. In option A, documenting an assessment that was not performed is falsification of health records because it misrepresents the care provided to the patient. Similarly, in option E, documenting that blood labs were sent before the blood draw was performed is a falsification of health records because it is not an accurate representation of the actual order of events.
Options B, C, and D do not involve falsification of health records, but they may be considered documentation errors or violations of organizational policies.
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