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. The nurse would explain to the patient that SCDs work by filling with air and applying intermittent or sequential pressure to the legs to enhance blood flow and venous return. This can help prevent blood clots, such as DVT, from forming in the legs. SCDs are often used for patients who are immobile, such as those who have undergone surgery or who are hospitalized for a medical condition. The device is comfortable to wear and can be adjusted to fit the patient's size and shape. The nurse would also explain the importance of wearing the device as prescribed, and how to properly use and care for it. By using SCDs as directed, the patient can significantly reduce their risk of developing a potentially life-threatening blood clot.
Correct Answer is ["C","E"]
Explanation
The nursing actions that best represent the step of performing interventions in the nursing process are:
C. The nurse ambulates a post-operative patient in the hall during their shift.
E. The nurse turns a patient every 2 hours to prevent pressure injuries.
Explanation: In the step of performing interventions, the nurse takes action to implement the nursing care plan and achieve the identified goals. The interventions should be specific, measurable, and realistic to address the patient's needs. Ambulating a post-operative patient in the hall during their shift and turning a patient every 2 hours to prevent pressure injuries are both specific interventions that address patient needs and promote positive health outcomes. Removing bandages from a burn victim's arm and performing sterile dressing change once a shift is more related to the step of assessment or implementation, while identifying a patient's priority health problem or assessing a patient's nutritional status are more related to the step of analysis and diagnosis in the nursing process.
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