Ch. 48
Which goals should the nurse identify as appropriate for a client with the nursing diagnosis Urinary Pattern Alteration related to an enlarged prostate? 1. The client will avoid bladder distention. 2. The client will maintain fluid imbalance. 3. The client will remain free of skin breakdown. 4. The client will voice increased discomfort.
Correct Answer: 1 Rationale 1: Avoiding bladder distention will help eliminate stasis of urine in the bladder, which contributes to urinary tract infections, a possible complication of urine flow being obstructed from an enlarged prostate. Rationale 2: One would want to maintain fluid balance, not imbalance, with a client with urinary obstruction and enlarged prostate. Keeping up with the client's intake and output would be a better goal. Rationale 3: It is important to keep urine off the skin to prevent breakdown, but with an enlarged prostate the problem will be more of the client retaining urine instead of it being on the skin. Rationale 4: One would hope that if the retention subsides, the client would voice less discomfort, not more.
A client is rushed to the emergency department with what the physicians suspect to be necrosis of the urinary diversion stoma. What evidence presented by the client leads to this conclusion? 1. Black with sloughing 2. Moist stoma 3. Pink and shiny 4. Slight bleeding from stoma
Correct Answer: 1 Rationale 1: Black color to the stoma and sloughing are signs of necrosis of the stoma. Rationale 2: A healthy stoma should appear moist. Rationale 3: A healthy stoma should appear pink and shiny. Slight bleeding might occur because the intestinal mucosa is very fragile. Rationale 4: Slight bleeding might occur because the intestinal mucosa is very fragile.
The nurse is assessing a client's urinary elimination. Which factor should the nurse keep in mind as influencing this elimination? 1. Age 2. Body image 3. Knowledge 4. Socioeconomic status
Correct Answer: 1 Rationale 1: Development factors such as how old the client is influence urinary elimination. Rationale 2: Body image does not influence urinary elimination. Rationale 3: Knowledge does not influence urinary elimination. Rationale 4: Socioeconomic status does not influence urinary elimination.
A client tells the nurse about the need to get up several times throughout the night to void. The nurse suspects the client is experiencing nocturia due to which factor? 1. Decrease in bladder tone 2. Decrease in blood supply 3. Decrease in number of nephrons 4. Decrease in cardiac output
Correct Answer: 1 Rationale 1: Nocturia is voiding frequently at night. An increased intake of fluid causes some increase in the frequency of voiding. Conditions such as urinary tract infection (UTI), stress, and pregnancy can cause frequent voiding of small quantities of urine. Total fluid intake and output may be normal. Rationale 2: A decrease in blood supply causes an increase in urine concentration. Rationale 3: A decrease in the number of nephrons decreases the filtration rate. Rationale 4: A decrease in cardiac output decreases peripheral circulation, which would decrease urinary output during both the day and the night.
A client has a spinal cord injury at the cervical spine area. The nurse realizes that this injury will affect which aspect of urinary elimination in the client? 1. Elimination of urine from the bladder 2. Ability of the kidneys to absorb solutes 3. Ureteral function 4. Urethra function
Correct Answer: 1 Rationale 1: The bladder contains the detrusor muscle, which is responsible for expulsion of urine from the bladder. If the client has a cervical spine injury, muscle function will be affected below the level of the injury, resulting in an impaired ability to eliminate urine from the bladder. Rationale 2: A cervical spine injury does not typically affect kidney function. Rationale 3: A cervical spine injury does not typically affect ureteral function. Rationale 4: A cervical spine injury does not typically affect urethra functioning.
The nurse is caring for a client with a urinary diversion. For which type of diversion should the nurse plan care for this client? 1. Incontinent urinary diversion 2. The kock pouch. 3. Neobladder 4. Nephrostomy
Correct Answer: 1 Rationale 1: This is an incontinent urinary diversion (ileal conduit). Rationale 2: This is not a continent urinary diversion. Rationale 3: This is not a neobladder. Rationale 4: This is not a nephrostomy.
The nurse is concerned that a client is at risk for the development of urinary tract infections. What did the nurse assess to come to this conclusion? 1. The client is wearing tight clothing. 2. The client is employed as a computer operator. 3. The client drinks 8-10 8-ounce glasses of water and low-calorie beverages each day. 4. The client exercises for 30-60 minutes most days of the week.
Correct Answer: 1 Rationale 1: Tight-fitting pants or other clothing can cause irritation to the urethra and prevent ventilation of the perineal area, leading to an infection. Rationale 2: Employment is not usually a risk factor for the development of a urinary tract infection. Rationale 3: This fluid intake would be sufficient to flush the urinary system and prevent the accumulation of bacteria and waste products. Rationale 4: Exercise is not a risk factor for the development of a urinary tract infection.
The nurse is instructing a client on ways to manage stress urinary incontinence. What should be included in this client's teaching? Standard Text: Select all that apply. 1. Limit intake of caffeine. 2. Limit intake of alcohol. 3. Increase intake of citrus juices. 4. Limit evening fluid intake. 5. Increase intake of beverages with artificial sweeteners.
Correct Answer: 1, 2, 4 Rationale 1: Clients with stress incontinence should be instructed to limit the intake of caffeine. Rationale 2: Clients with stress incontinence should be instructed to limit the intake of alcohol. Rationale 3: Clients with stress incontinence should be instructed to limit, not increase, the intake of citrus juices. Rationale 4: Clients with stress incontinence should be instructed to limit evening fluid intake. Rationale 5: Clients with stress incontinence should be instructed to limit, not increase, the intake of beverages with artificial sweeteners.
An older female client with a history of urinary tract infections has an indwelling urinary catheter. What should the nurse do to reduce this client's risk of developing an infection because of the catheter? Standard Text: Select all that apply. 1. Maintain a sterile closed drainage system. 2. Clean the peri-urethral area with antiseptics. 3. Ensure the catheter and tubing are not kinked. 4. Wash his or her hands before manipulating the catheter. 5. Keep the collection bag below the level of the bladder.
Correct Answer: 1, 3, 4, 5 Rationale 1: To prevent a urinary tract infection in the presence of an indwelling urinary catheter, the nurse should maintain a sterile closed drainage system. Rationale 2: Cleaning the peri-urethral area with antiseptics is an action that should be avoided. Rationale 3: To prevent a urinary tract infection in the presence of an indwelling urinary catheter, the nurse should maintain unobstructed urine flow by making sure the catheter and tubing are not kinked. Rationale 4: To prevent a urinary tract infection in the presence of an indwelling urinary catheter, the nurse should wash his or her hands before any manipulation of the catheter or collection system. Rationale 5: To prevent a urinary tract infection in the presence of an indwelling urinary catheter, the nurse should keep the collection bag below the level of the bladder at all times.
A client is complaining of pain with urination. The nurse realizes that the client needs to be assessed for which health problems? Standard Text: Select all that apply. 1. Urethral stricture 2. Renal failure 3. Urethral injury 4. Bladder injury 5. Urinary infection
Correct Answer: 1, 3, 4, 5 Rationale 1: Dysuria means voiding that is either painful or difficult. It can occur with a urethral stricture. Rationale 2: Dysuria means voiding that is either painful or difficult. It is not typically associated with renal failure. Rationale 3: Dysuria means voiding that is either painful or difficult. It can occur with a urethral injury. Rationale 4: Dysuria means voiding that is either painful or difficult. It can occur with a bladder injury. Rationale 5: Dysuria means voiding that is either painful or difficult. It can occur with a urinary infection.
The nurse is documenting the insertion of a retention catheter for a client. What should be included in this documentation? Standard Text: Select all that apply. 1. Catheter size 2. Location of the drainage bag 3. Amount of urine that drained after insertion 4. Name of the physician who prescribed the insertion of the catheter 5. Client tolerance of the procedure
Correct Answer: 1, 3, 5 Rationale 1: The nurse should document the catheterization procedure, including the catheter size. Rationale 2: The nurse does not need to document the location of the drainage bag. Rationale 3: The nurse should document the amount of urine that drained after insertion. Rationale 4: The nurse does not need to document the name of the physician who prescribed the insertion of the catheter. Rationale 5: The nurse should document the client's tolerance of the procedure.
A client's urine pH is 8.0. What further assessments would be indicated for this client? Standard Text: Select all that apply. 1. Intake of fruits and vegetables 2. Intake of cranberries 3. Intake of high-protein foods 4. Symptoms of diarrhea 5. Symptoms of a urinary tract infection
Correct Answer: 1, 5 Rationale 1: Alkaline urine might indicate a diet high in fruits and vegetables. Rationale 2: Acidic urine is found in an intake high in cranberries. Rationale 3: Acidic urine is found in a diet high in proteins. Rationale 4: Acidic urine is found with diarrhea. Rationale 5: Alkaline urine might indicate a urinary tract infection.
A client has been admitted with incontinence. What should the nurse expect to assess in this client? 1. Client is wearing cotton undergarments. 2. Leakage of urine occurs when client laughs. 3. Leakage of urine occurs when talking with the client. 4. The skin of the client is clear without discoloration.
Correct Answer: 2 Rationale 1: A client with incontinence would wear some kind of undergarment pad. Cotton undergarments alone would not provide protection for catching the urine. Rationale 2: Incontinence involves a small leakage of urine when a client laughs. Rationale 3: Incontinence does not occur if a client just carries on a conversation. Rationale 4: If the client has been experiencing incontinence, the nurse might expect to see the skin inflamed and irritated because urine is very irritating to the skin.
A client is prescribed propranolol (Inderal). What should the nurse instruct the client about this medication? 1. The medication should be discontinued abruptly. 2. Notify the physician if you experience urinary retention. 3. Take a laxative every day. 4. Take the medication on an empty stomach.
Correct Answer: 2 Rationale 1: Clients should always check with their physician before stopping any medication because there could be some major complications. Rationale 2: A beta-adrenergic blocker such as propranolol can cause urinary retention; therefore, it would be of the utmost importance to notify the physician. Rationale 3: Constipation has been reported from clients taking propranolol, but a laxative should not be taken every day, as one can become dependent. Rationale 4: This medicine should be taken with food, not on an empty stomach, in order to enhance absorption.
A client recovering from a transurethral resection of the prostate (TURP) with a three-way indwelling catheter expresses the need to urinate. Which action should the nurse take to help this client? 1. Deflate and then reinflate the balloon. 2. Irrigate the catheter. 3. Reposition the catheter. 4. Retape the catheter to the abdomen.
Correct Answer: 2 Rationale 1: Deflating and reinflating the balloon is not an option. The surgeon knows how much pressure is needed to control bleeding after surgery. Rationale 2: Blood clots give the client the sensation to urinate when they obstruct the urine outflow; therefore, irrigation will have to remedy the problem. Rationale 3: Repositioning the catheter would not be an option right after surgery. Rationale 4: The catheter is usually taped to the client's leg after a TURP and is not to be manipulated. This also controls bleeding after surgery.
The nurse should incorporate which instructions into the teaching plan for a client with a urinary diversion? 1. Change the appliance several times a day. 2. Increase fluid intake. 3. Notify the physician if the stoma is deep pink and shiny. 4. Strands of blood may appear in the urine.
Correct Answer: 2 Rationale 1: The appliance should be changed as necessary. Changing the appliance too frequently can cause skin breakdown. Rationale 2: Increasing the fluid intake helps to flush out sediment and mucus and prevents clogging of the stoma. Rationale 3: A deep pink, shiny stoma is normal, and there's no need to notify the physician. Rationale 4: Strands of mucus, not blood, may appear in urine because of the mucus-producing cells of the ileum.
A client is having issues with urinary elimination. What should the nurse instruct this client to promote urinary elimination? 1. Don't interrupt your day by going to the bathroom; wait until you're at a good stopping place. 2. Drink 8 to 10 glasses of water daily. 3. Urine color changes are not important. 4. Wash with soap and water every other day.
Correct Answer: 2 Rationale 1: The client should respond to the urge to void as soon as possible to avoid urinary retention. Rationale 2: Drinking 8 to 10 glasses of water daily will encourage the need for bladder emptying, keeping the system flushed. Rationale 3: The client should report any changes in urine color, which could be indicative of a problem. Rationale 4: To maintain asepsis, the client should wash with soap and water every day, not every other day.
The nurse is performing urinary catheterization for a client. After using the nondominant hand to separate the client's labia for cleansing, the nurse will maintain this hand as being 1. sterile. 2. contaminated. 3. able to evaluate the effectiveness of the catheter balloon. 4. clean.
Correct Answer: 2 Rationale 1: The hand is contaminated after touching the client's skin. Rationale 2: When performing urinary catheterization, the nondominant hand is considered contaminated once it touches the client's skin. Rationale 3: The hand should not be used to touch any equipment once it touches the client's skin. Rationale 4: The hand is contaminated, not clean, after touching the client's skin.
The nurse has completed closed irrigation of a client's retention catheter. What specific information should the nurse document about this procedure? 1. Number of ml of solution used to inflate the balloon of the catheter 2. Abnormal drainage, such as blood clots, pus, or mucous shreds 3. Location of the draining bag 4. Technique used to conduct the irrigation
Correct Answer: 2 Rationale 1: The nurse does not need to document the number of ml of solution used to inflate the balloon of the catheter, as the catheter already was in place. Rationale 2: The nurse should note any abnormal constituents, such as blood clots, pus, or mucous shreds. Rationale 3: The nurse does not need to document the location of the drainage bag. Rationale 4: The nurse does not need to document the technique used to conduct the irrigation.
Which nursing diagnosis would be appropriate for a client who has a retention catheter if the drainage bag is found lying on the floor? 1. Risk for Impaired Skin Integrity related to catheter placement 2. Risk for Infection related to improper handling 3. Self-Care Deficit related to presence of a retention catheter 4. Risk for Incontinence related to an obstruction
Correct Answer: 2 Rationale 1: There is a possibility of skin impairment with a catheter, but the emphasis here is on where the drainage bag was found. Rationale 2: The floor is the dirtiest place, so the drainage device should never be placed on the floor. Rationale 3: Even though a client has a catheter in place, it does not restrict one from providing self-care. The client may need some assistance. Rationale 4: The placement of a catheter prevents incontinence; it does not add to it. Patency of the catheter ensures flow, not obstruction.
A client is diagnosed with an elevated aldosterone level. The nurse realizes that this finding will affect what aspect of urinary elimination? 1. Increased urine output 2. Urinary incontinence 3. Decreased urine output 4. Urinary retention
Correct Answer: 3 Rationale 1: Elevated aldosterone levels will not increase the urine output. Rationale 2: Elevated aldosterone levels do not cause urinary incontinence. Rationale 3: When aldosterone is released from the adrenal cortex, sodium and water are reabsorbed in greater quantities, increasing the blood volume and decreasing urinary output. Rationale 4: Elevated aldosterone levels do not cause urinary retention.
The nurse is concerned that an older client with a retention catheter is developing a urinary tract infection. What assessment finding caused this concern? 1. Elevated blood pressure 2. Elevated heart rate 3. Confusion 4. Leg pain
Correct Answer: 3 Rationale 1: Elevated blood pressure is not a sign of urinary tract infection. Rationale 2: Elevated heart rate is not a sign of urinary tract infection. Rationale 3: In the older client, confusion can be an early sign of urinary tract infection. Rationale 4: Leg pain is not a sign of urinary tract infection.
The nurse is identifying outcomes for a client with the nursing diagnosis Stress Urinary Incontinence. Which outcome would be related to sphincter incompetence? 1. The client will empty her bladder every time she voids. 2. The client will improve her incontinence within 1 month. 3. The client will perform four to five squeezes for 5 to 10 seconds. 4. The client will stop the flow of urine when voiding.
Correct Answer: 3 Rationale 1: Emptying the bladder completely every time she voids would not be realistic in the beginning. This will take time. Rationale 2: Improved continence takes 3 to 6 months, so 1 month is not a realistic goal. Rationale 3: Performing four to five squeezes for 5 to 10 seconds is the goal to start with when teaching a client Kegel exercises, which are used for stress and urge incontinence. Rationale 4: Clients are not instructed to stop the flow of urine when voiding because this could lead to retention.
Which intervention would the nurse plan to help a client prevent a urinary tract infection? 1. Encourage the use of bubble baths. 2. Have the client increase sugar in the diet. 3. Instruct the client to empty the bladder completely. 4. Wipe from back to front.
Correct Answer: 3 Rationale 1: Irritating soaps and bubble baths can contribute to infections and should be avoided. Rationale 2: The client should decrease the amount of sugar in the diet because sugar promotes bacterial growth. Rationale 3: Completely emptying the bladder prevents stasis of urine, which would contribute to a urinary tract infection. Rationale 4: The client should wipe from front to back because wiping from back to front would contaminate the urinary meatus.
The nurse realizes that which client is at risk for difficulty in urinary elimination? 1. A client who had bladder cancer and now has a newly created ileal conduit 2. A 25-year-old female client with low self-esteem 3. An 80-year-old male reporting frequent urination at night 4. The client with hypertension who takes a diuretic every day for blood pressure
Correct Answer: 3 Rationale 1: The client who had bladder cancer and now has an ileal conduit doesn't have kidney damage, only the bladder removed. Continued urine production through the ileal conduit will need to be observed and assessed frequently by the staff. Rationale 2: The 25-year-old experiencing low self-esteem has a psychological problem and will need therapy to find the root of the problem. Rationale 3: The client who is 80 years old with frequent urination at night is having problems with his prostate. Older male adults experience urinary retention due to prostate enlargement causing an alteration in urinary elimination. Rationale 4: The client with high blood pressure takes her medication to remove excess fluid from the body, and as long as urine elimination increases, there should be no problems.
A client's urinalysis is reported as being normal. What were the client's results? 1. Blood present and no ketones 2. Dark amber color and output less than 500 cc in 24 hours 3. pH 6 and no glucose present 4. Specific gravity 1.035 and faint aromatic odor
Correct Answer: 3 Rationale 1: There should be no blood present as well as no ketones. Rationale 2: The urine should be an amber color, not dark amber. For an adult, normal output range is 1,200 to 1,500 mL in 24 hours. Rationale 3: Normal pH is 4.5 to 8, so a pH of 6 and no glucose present are two normal characteristics of urine. Rationale 4: A specific gravity of 1.035 does not fall within the normal range of 1.010 to 1.025, but a faint aromatic odor is normal.
A client needs a test to determine the amount of residual urine. The nurse realizes that this assessment is used for which reason(s)? Standard Text: Select all that apply. 1. To evaluate the glomerular filtration rate 2. To determine the extent of renal failure 3. To determine the amount of retained urine after voiding 4. To determine the need for medications 5. To evaluate fluid volume status
Correct Answer: 3, 4 Rationale 1: Residual urine is not measured to evaluate the glomerular filtration rate. Rationale 2: Residual urine is not measured to determine the extent of renal failure. Rationale 3: Residual urine is measured to assess the amount of retained urine after voiding. Rationale 4: Residual urine is measured to determine the need for interventions such as medications. Rationale 5: Residual urine is not measured to evaluate fluid volume status.
A client's results from a urinalysis are as follows: pH 5.2, gross cloudiness, WBC 10-15, glucose negative, specific gravity 1.012, and protein negative. How should the nurse interpret the results? 1. Dehydration 2. Diabetic ketoacidosis 3. Trauma 4. Urinary tract infection
Correct Answer: 4 Rationale 1: An elevated specific gravity is seen in dehydration. Rationale 2: The glucose would be elevated in diabetic ketoacidosis. Rationale 3: Blood would be present in trauma. Rationale 4: The pH, glucose, specific gravity, and protein are all within normal limits. Urine is usually clear to slightly cloudy, and WBC count can be from 0 to 4. Therefore, the gross cloudiness and WBC count of 10-15 are not normal, indicating a urinary tract infection.
Which nursing intervention is appropriate when caring for a client with a retention catheter? 1. Don sterile gloves. 2. Gently retract the labia majora away from the urinary meatus. 3. Observe urine in the drainage bag. 4. Retape the catheter to the thigh.
Correct Answer: 4 Rationale 1: Gloves are to be worn for cleaning but not sterile gloves. Rationale 2: When giving catheter care to a female, the labia minora is gently retracted away from the urinary meatus, not the labia majora. Rationale 3: The urine in the tubing should be observed, not the urine in the bag. Observing the urine in the tubing promotes accurate assessment of urine. Rationale 4: Retaping the catheter to the thigh after care is given prevents trauma and pain from tension and pulling.
A client is instructed on the care of an indwelling urinary catheter. Which returned demonstration by the client indicates that teaching has been effective? 1. The client empties the drainage bag once a day. 2. The client hangs the drainage bag on the towel rod. 3. The client refuses drinks one to two 8-ounce glasses of fluid each day. 4. The client takes a shower each day.
Correct Answer: 4 Rationale 1: The drainage bag should be emptied regularly, not just once a day but at least three times a day. Rationale 2: Hanging the drainage bag on the towel rod is too high. The drainage bag should be hung below the bladder. Rationale 3: Adequate amounts of fluids should be consumed to help prevent sediments and infections. Rationale 4: The client should take a shower rather than a tub bath because sitting in a tub allows bacteria to easily access the urinary tract.
The nurse is applying an external urinary device to a client. Before attaching the device to the drainage bag, what should the nurse do? 1. Wash his or her hands. 2. Document the client's tolerance of the procedure. 3. Instruct the client about the drainage system. 4. Ensure that the condom is not twisted.
Correct Answer: 4 Rationale 1: The nurse should wash his or her hands before and after the procedure. Rationale 2: The nurse should document after the procedure is completed. Rationale 3: The nurse should instruct the client about the drainage system after attaching the bag to the device. Rationale 4: The nurse should make sure that the tip of the penis is not touching the condom and that the condom is not twisted, because a twisted condom could obstruct the flow of urine.
A client with an indwelling urinary catheter is prescribed to receive sterile normal saline bladder irrigation at 100 mL/hr. After an 8-hour shift the nurse measures the client's output as being 1425 mL. What is the client's urine output for the 8-hour shift? Standard Text: Calculate to the nearest whole number.
Correct Answer: 625 mL Rationale: The client is to receive 800 mL of bladder irrigant for the 8-hour shift. The nurse needs to subtract the bladder irrigant total from the total output, or 1425 - 800 = 625 mL. This is the client's urine output for the 8-hour shift.
The nurse wants to delegate the application of a condom catheter to unlicensed assistive personnel (UAP). What must the nurse assess prior to delegating this task? 1. Assess whether the client has unique needs. 2. Measure the client's intake. 3. Assist the client out of bed to a chair. 4. Assess changes in the client's mobility status.
Correct Answer: 1 Rationale 1: Applying a condom catheter may be delegated to UAP. However, the nurse must determine whether the specific client has unique needs, such as impaired circulation or latex allergy, that would require special training of the UAP in the use of the condom catheter. Rationale 2: The nurse does not need to measure the client's intake before delegating the application of a condom catheter to UAP. Rationale 3: The nurse does not need to assist the client out of bed to a chair before delegating the application of a condom catheter to UAP. Rationale 4: The nurse does not need to assess changes in the client's mobility status before delegating the application of a condom catheter to UAP.
The RN is admitting a client to the medical unit for a urinary disorder. Which physical assessment techniques should the nurse use in assessing this client's urinary system? 1. Auscultation and inspection 2. Inspection and percussion 3. Observation and auscultation 4. Palpation and observation
Correct Answer: 4 Rationale 1: The nurse will not use auscultation when assessing the client's urinary system. Rationale 2: The percussion technique is the least frequently used by nurses, and it would cause discomfort if this client is already uncomfortable with a kidney condition. The nurse should not make matters worse. Rationale 3: The nurse will not use auscultation when assessing the client's urinary system. Rationale 4: The hands and sense of touch are used with palpation to gather data along with observation or inspection, which visually allows the nurse to observe all responses and nonverbal behavior. It is also the most frequently used technique and the most convenient.
The nurse is determining tasks to delegate to unlicensed assistive personnel (UAP). Which task should the nurse question before delegating to this level of health care provider? 1. Measuring intake and output 2. Assessing vital signs for clients who are clinically stable 3. Performing complete morning care for a client recovering from a stroke 4. Inserting a urinary catheter into a client
Correct Answer: 4 Rationale 1: This skill can be delegated to UAP. Rationale 2: This skill can be delegated to UAP. Rationale 3: This activity can be delegated to UAP. Rationale 4: Due to the need for sterile technique and detailed knowledge of anatomy, insertion of a urinary catheter is not delegated to UAP.
A UAP has applied a condom catheter to a client. The nurse should document what information about this procedure? Standard Text: Select all that apply. 1. Number of ml of fluid used to inflate the balloon 2. Location of the drainage bag 3. Name of the UAP who applied the device 4. Time and date that the condom catheter was applied 5. Integrity of the penis
Correct Answer: 4, 5 Rationale 1: A condom catheter does not have a balloon that needs to be inflated. Rationale 2: The nurse does not need to document the location of the drainage bag. Rationale 3: The nurse does not need to document the name of the UAP who applied the device. Rationale 4: The nurse should document the application of the condom, including the time. Rationale 5: The nurse should document any pertinent observations, such as the integrity of the penis.
