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 B

Explanation

A. Advise the UAP to hold the thermometer securely in place for a full three minutes is incorrect because tympanic thermometers provide quick readings, typically within a few seconds, and do not require prolonged placement.

B. Use positive reinforcement to affirm that the procedure is being performed correctly is the correct action. For adult clients, the auricle should be pulled up and back to straighten the ear canal for accurate tympanic temperature measurement. Positive reinforcement supports the UAP's learning and confidence.

C. Demonstrate the correct technique for pulling the client's auricle down and back is incorrect for adult clients. Pulling the auricle down and back is appropriate for children under 3 years old, not adults.

D. Remind the UAP to lubricate the thermometer before gently inserting in the ear is not appropriate. Tympanic thermometers do not require lubrication, as they are designed for non-invasive and quick use.

A. Provide a box of tissues for the client to use when coughing. B. Obtain face masks for staff to wear upon entering the room. C. Assist the client in changing into a fresh hospital gown. D. Teach the client to cover the mouth with hands when coughing.

Correct Answer is B

Explanation

A. Provide a box of tissues for the client to use when coughing is a helpful action for promoting hygiene and comfort. However, this does not address the potential risk of infection transmission to staff and others in the room.

B. Obtain face masks for staff to wear upon entering the room is the most appropriate action. The client is coughing, and non-productive coughing can still release droplets that may carry infectious agents. Wearing face masks helps protect staff and other individuals from potential exposure to airborne pathogens.

C. Assist the client in changing into a fresh hospital gown is a considerate action but does not directly address the immediate concern of infection control. The priority here is preventing the spread of potential infectious particles.

D. Teach the client to cover the mouth with hands when coughing is incorrect. The client should cover their cough with their elbow or a tissue, not with their hands, to prevent spreading germs. Teaching this technique is important but does not address the immediate need for protective measures for staff.

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

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Naxlex Comprehensive Predictor Exams

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