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Saunders Nclex-PN - Elimination Exam Questions And 100% Correct Answers
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Saunders Nclex-PN - Elimination Exam Questions And 100%Correct Answers
A nurse is performing the insertion of an indwelling urinary catheter on a male client. At
the time of advancement of the catheter through the urethra, urine begins to flow into
the tubing. When should the nurse inflate the balloon?
1. Immediately inflate the balloon.
2. Insert catheter 2.5 cm to 5 cm and inflate the balloon.
3. Advance the catheter to the bifurcation and inflate the balloon.
4. Insert catheter until resistance is met and inflate the balloon.
3. Advance the catheter to the bifurcation and inflate the balloon.
Rationale:
The catheterization of the urine is a sterile procedure. During the insertion of the
indwelling catheter, the nurse must advance the balloon in the bladder before inflating
it. If the balloon is inflated in the urethra of the male client, trauma may result. In male
catheterization, after noting the flow of urine through the tubing, the nurse continues to
insert the catheter to the point of bifurcation and then inflates the balloon. After that, the
nurse pulls the catheter back until slight resistance is felt, then applies a tube holder
onto the thigh to secure the catheter in place. The balloon should not be inflated when
urine is first observed after advancing several more centimeters, or when resistance is
felt.
Which of the following is the most appropriate catheter for a male client who presents
with severe urinary retention, history of UTIs, and a stage 4 pressure injury on his
coccyx?
,1
2
3
4
3
Rationale:
Long-term indwelling catheters are utilized with severe urinary retention, recurrent
urinary tract infections, and when wounds are irritated by contact with urine. Silicon is
preferred because it can stay in place for 2 to 3 months. Size 14 to 16 are standard sizes
and only sterile water should be utilized to inflate the balloon. Saline will crystallize in
the balloon. Intermittent and short-term catheterization would not solve the issue of
severe urinary retention and would require repeated catheterization, increasing risk of
infection. A condom catheter will not remedy urinary retention and does not have a
balloon.
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, The nurse is discharging a postoperative female client who developed a UTI
postoperatively. What critical topics related to UTIs would the nurse want to stress in
the discharge instructions? (Select all that apply.)
alk #1 Drink at least 2 quarts of fluid daily.
alk #2 Void at least every 8 hours throughout the day.
alk #3 Avoid vaginal douching and/or using harsh soaps, bubble bath, powders, and
sprays in the perineal area.
4. Take all discharge medication as prescribed including antibiotics, and notify your
primary health care provider if symptoms or signs of a UTI reappear.
5. Practice good hygiene including cleaning the perineum by separating the labia,
cleaning with warm soapy water after a bowel movement, and wiping from front to back
after urinating.
(1, 3, 4 & 5)
Rationale:
Along with taking all medications ordered at discharge, including antibiotics, and calling
the primary health care provider if symptoms/ signs of a UTI occur, the client should
also take adequate amounts of fluids and practice appropriate hygiene to minimize the
risk of organisms entering the bladder. Vaginal douches should not be used nor any
other products that can cause irritation to the perineal area. The client should be
instructed to void at least every 4 to 6 hours.
Which of the following information does the nurse include when reinforcing client
teaching about ostomy care? Select all that apply.
1.The appliance should be changed daily.
2.The pouch should be emptied when it is ⅓ to ½ full.
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