Nokea
After inserting an indwelling catheter into a male client, which technique is most appropriate for stabilizing the catheter to avoid damage to the penis?
- A. Tape the catheter to the abdomen.
- B. Pass the catheter under the client's leg.
- C. Fasten the drainage tubing to the bed with a safety pin.
- D. I'm very the catheter into the tubing of a collecting bag.
Correct Answer: A
Rationale: Taping the catheter to the abdomen stabilizes it without causing traction or damage to the penis, promoting comfort and safety.
You may also like to solve these questions
Before administering an analgesic to the client, which information is most important for the nurse to assess?
- A. Whether the urine is bloody
- B. Whether the client has been up walking in the room
- C. Whether the catheter is draining urine
- D. Whether the client has been drinking adequate fluids
Correct Answer: C
Rationale: Ensuring the catheter is draining urine is critical to prevent bladder distention, which could exacerbate discomfort.
The client returned from surgery after having a TURP and has a P 110, R 24, BP 90/40, and cool and clammy skin. Which interventions should the nurse implement? Select all that apply.
- A. Assess the urine in the continuous irrigation drainage bag.
- B. Decrease the irrigation fluid in the continuous irrigation catheter.
- C. Lower the head of the bed while raising the foot of the bed.
- D. Contact the surgeon to give an update on the client’s condition.
- E. Check the client’s postoperative creatinine and BUN.
Correct Answer: A,C,D
Rationale: Tachycardia, hypotension, and clammy skin suggest hypovolemic shock, likely from bleeding. Assess urine for blood, use Trendelenburg to improve perfusion, and notify the surgeon. Decreasing irrigation may worsen clotting, and lab checks are less urgent.
The nurse and an unlicensed assistive personnel (UAP) are caring for a group of clients. Which nursing intervention should the nurse perform?
- A. Measure the client’s output from the indwelling catheter.
- B. Record the client’s intake and output on the I&O sheet.
- C. Instruct the client on appropriate fluid restrictions.
- D. Provide water for a client diagnosed with diabetes insipidus.
Correct Answer: C
Rationale: Instructing on fluid restrictions requires nursing judgment and education skills, which are outside the UAP’s scope. Measuring output, recording I&O, and providing water are delegable tasks.
The client diagnosed with cancer of the bladder is scheduled to have a cutaneous urinary diversion procedure. Which preoperative teaching intervention specific to the procedure should be included?
- A. Demonstrate turn, cough, and deep breathing.
- B. Explain a bag will drain the urine from now on.
- C. Instruct the client on the use of a PCA pump.
- D. Take the client to the ICD so the client can become familiar with it.
Correct Answer: B
Rationale: A cutaneous urinary diversion (e.g., ileal conduit) requires a stoma and drainage bag. Explaining this prepares the client for post-op care. Coughing/breathing, PCA use, and ICU visits are general, not specific.
Which response by the nurse is most appropriate?
- A. His bladder retraining is coming along, and before long he will be urinating like normal.
- B. He seems to have more incontinence in the afternoon and evening.
- C. In order to protect his privacy, I can't give you that information.
- D. Bladder retraining is slow work. We have to take him to the toilet every 2 hours.
Correct Answer: C
Rationale: To comply with HIPAA, the nurse must protect the client's privacy and not disclose health information without consent, making this the most appropriate response.