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. Irrigate the nasogastric tube with water may be necessary if the tube is clogged, but it does not address the immediate concern of the client choking. The priority is ensuring the client’s airway is clear.

B. Elevate the head of bed 45 degrees is a useful intervention for reducing aspiration risk, but it does not address the immediate need to clear the airway when the client is choking. Elevating the head of the bed could be helpful after the airway is cleared.

C. Review the advanced directive document is important for understanding the client’s wishes, but the immediate priority is addressing the choking. The nurse should focus on clearing the airway first, then review the advanced directive as appropriate.

D. Perform oropharyngeal suctioning is the most appropriate action. The client is vomiting and choking, which suggests a risk of airway obstruction. Oropharyngeal suctioning will help clear the airway and prevent aspiration, which is the priority in this situation.

A. Dons sterile gloves when caring for clients with HIV. B. Uses sterile gloves when handling body fluids. C. Keeps a pair of gloves in uniform pocket. D. Puts on new gloves when entering a client's room.

Correct Answer is B

Explanation

A. Dons sterile gloves when caring for clients with HIV is incorrect. HIV is transmitted through specific body fluids such as blood, semen, and vaginal fluids, but sterile gloves are not required for routine care unless there is a risk of exposure to these fluids. Standard precautions are used for all clients, regardless of their diagnosis.

B. Uses sterile gloves when handling body fluids is correct. Sterile gloves are used in situations where there is a high risk of contamination, such as when handling body fluids that may contain infectious agents, or during invasive procedures.

C. Keeps a pair of gloves in uniform pocket is incorrect. Gloves should not be stored in pockets as this may compromise their sterility or cleanliness. Gloves should be stored in a clean, dry place.

D. Puts on new gloves when entering a client's room is incorrect. Gloves should be worn when necessary, such as when there is a risk of contact with body fluids or contaminated surfaces. They should not be put on automatically without assessing the situation.

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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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Explanation

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Correct Answer is B

Explanation

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