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 C

Explanation

A. Explain that alternative treatment options may be helpful is not appropriate at this moment. The spouse is expressing grief, and the focus should be on emotional support rather than discussing medical treatment options, which may not be relevant to the spouse’s current emotional state.

B. Offer reassurance that the spouse is not alone may provide some comfort but does not address the underlying need for the spouse to express their emotions. It is more important to listen and allow the spouse to share their feelings first.

C. Encourage the spouse to share their feelings is the most appropriate first response. The spouse is expressing emotional distress, and the nurse should offer a safe space for the spouse to talk about their feelings. This approach helps to validate the spouse’s emotions and provides an opportunity for emotional support.

D. Remind the spouse that the client may still live a long time is not appropriate because it could invalidate the spouse’s feelings of loss and grief. The spouse is dealing with the reality of the terminal illness, and the nurse should not offer false hope or minimize the situation.

A. Warm, dry skin with a fever of 100.0° F (37.8° C). B. 4+ pitting edema of both lower extremities. C. A Braden risk assessment scale rating score of ten. D. Hypoactive bowel sounds with infrequent bowel movements.

Correct Answer is C

Explanation

A. Warm, dry skin with a fever of 100.0° F (37.8° C) is not directly related to the need for frequent turning. A fever and warm, dry skin may indicate an infection or another underlying condition, but it does not prioritize the need for turning in the context of pressure injury prevention.

B. 4+ pitting edema of both lower extremities may indicate fluid retention, but it is not as directly related to the risk of developing pressure injuries. Although edema can impact skin integrity, the Braden scale score is a more reliable indicator for turning schedules to prevent pressure ulcers.

C. A Braden risk assessment scale rating score of ten is the most important factor in determining the turning schedule. A score of ten indicates a high risk for developing pressure ulcers, which is directly related to the need for frequent repositioning to relieve pressure and prevent skin breakdown.

D. Hypoactive bowel sounds with infrequent bowel movements may be a concern for gastrointestinal function, but it does not directly affect the turning schedule. The Braden scale score is a better indicator for deciding how often the client needs to be turned to prevent pressure injuries.

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

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