The nurse orients a client with depression to a new room on the mental health unit. The client states, “It seems strange that I don’t have a television (TV) in my room.” Which statement is best for the nurse to provide?

Choice A reason: Positioning the sterile field at hip level maintains sterility but is not specific to uncircumcised clients. Cleaning the meatus before retracting the foreskin prevents infection by removing bacteria first. This is secondary, per infection control and catheterization procedure standards in nursing practice.

Choice B reason: Cleaning the meatus before retracting the foreskin removes bacteria, reducing infection risk in uncircumcised clients. This sequence ensures sterility before exposing sensitive areas, critical for preventing urinary tract infections, per evidence-based catheterization and infection control protocols in urological nursing care.

Choice C reason: Wiping the meatus in backward strokes is incorrect, as circular strokes from meatus outward are standard to avoid contamination. Cleaning before retracting the foreskin is critical for infection prevention. This violates sterile technique, per catheterization and infection control standards in nursing.

Choice D reason: Advancing the catheter before inflating the balloon is standard but not specific to uncircumcised clients. Cleaning the meatus first addresses foreskin-related infection risks. Balloon inflation timing is universal, per indwelling catheter insertion and urological care protocols in nursing practice.

Choice A reason: Administering an IV narcotic masks pain without addressing its cause. Pain at the PCI site may indicate hematoma or arterial injury, common post-PCI due to vessel trauma and tirofiban’s antiplatelet effects. Assessing the site identifies bleeding, critical to prevent complications like hemorrhage before providing analgesia.

Choice B reason: Adjusting the compression device without assessment risks worsening a hematoma, as excessive pressure impairs flow, while insufficient pressure fails to control bleeding. Tirofiban increases bleeding risk. Assessing for hematoma ensures proper management, preventing vascular complications, making adjustment premature without confirming the pain’s cause.

Choice C reason: Turning to a left side-lying position does not address PCI site pain, potentially from hematoma or arterial injury. Post-PCI, supine positioning minimizes site stress. Assessing for hematoma, exacerbated by tirofiban’s anticoagulation, is critical to detect bleeding, preventing complications like retroperitoneal hemorrhage over positional changes.

Choice D reason: Assessing the femoral PCI site for hematoma is essential, as pain may indicate bleeding, common post-PCI with tirofiban’s platelet inhibition. Hematoma can compress vessels, causing ischemia or rupture, requiring urgent intervention like compression or surgery. This addresses the pathophysiological risk, ensuring vascular stability and patient safety.