Which action should the nurse implement when inserting an indwelling catheter for an uncircumcised male client?

Clean the urinary meatus before retracting the foreskin.

Position the sterile field even with the nurse's hips.

Use a swab to wipe the meatus in back-and-forth motions.

Advance the catheter before inflating the balloon.

Answer and Explanation

The Correct Answer is A

A. Clean the urinary meatus before retracting the foreskin is the correct action. Before retracting the foreskin, the nurse should clean the meatus to prevent contamination of the catheterization site. This ensures that any bacteria present are removed before inserting the catheter.

B. Position the sterile field even with the nurse's hips is not directly related to the procedure for an uncircumcised male client. The sterile field should be positioned at a level where the nurse can comfortably reach it without contaminating it, but this does not specifically address the care of an uncircumcised male.

C. Use a swab to wipe the meatus in back-and-forth motions is incorrect. The meatus should be cleaned using a circular motion, starting at the meatus and working outward. Back-and-forth motions could cause contamination of the area.

D. Advance the catheter before inflating the balloon is an appropriate action during catheter insertion; however, this is not specific to the care of an uncircumcised male client. The balloon should be inflated only after the catheter is fully inserted and urine flow is confirmed.

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Correct Answer is D

Explanation

A. Self-care deficit might apply if the client is unable to perform foot care independently. However, the priority concern is addressing the potential complications of neuropathy, such as skin breakdown, before considering assistance with care.

B. Risk for infection is a valid concern, especially if skin integrity is compromised. However, infection prevention depends on maintaining intact skin, making skin integrity the more immediate priority.

C. Impaired physical mobility may contribute to challenges in foot care but does not directly address the risk posed by neuropathy, which primarily affects sensory perception and increases vulnerability to unnoticed injuries.

D. Risk for impaired skin integrity is the priority because neuropathy reduces sensation in the feet, increasing the likelihood of unnoticed injuries, pressure sores, or burns. Early identification and prevention of skin damage are essential for avoiding complications.

A. The client will adhere to the medication regimen after discharge. B. The client attempts to self-administer insulin but is unable to perform injection. C. The client will demonstrate ability to change the ostomy bag in two days. D. The client's breath sounds will be auscultated by the nurse every 4 hours.

Correct Answer is A

Explanation

A. The client will adhere to the medication regimen after discharge is an appropriate outcome statement because it is specific to the client's need to manage hyperglycemia with insulin therapy postoperatively. This outcome addresses the necessity of learning self-injection techniques and adhering to the prescribed regimen.

B. The client attempts to self-administer insulin but is unable to perform injection is not an appropriate outcome statement because it does not reflect a desired or achievable goal. It implies failure rather than a measurable improvement.

C. The client will demonstrate ability to change the ostomy bag in two days is relevant to the colostomy care but does not address the immediate need for managing hyperglycemia with insulin therapy.

D. The client's breath sounds will be auscultated by the nurse every 4 hours is a task-oriented intervention rather than a client-centered outcome statement.

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Which action should the nurse implement when inserting an indwelling catheter for an uncircumcised male client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is A

Explanation

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