A. Measure the patient's urinary output:
Measuring output is important but not the priority. First, the nurse must ensure that urine can drain freely.
B. Ensure that the catheter tubing is not kinked:
This is the priority. A kinked catheter can cause bladder distention and discomfort, leading to a sensation of urgency despite the catheter being in place.
C. Provide perineal care to the patient for comfort:
Comfort is important, but it does not address the potential cause of the urinary sensation.
D. Reassure the patient that the sensation is to be expected:
Sensation may be expected in some patients, but it’s essential to rule out mechanical obstruction first.

A. Reattach the syringe and attempt to withdraw more water from the balloon:
Occasionally, fluid remains in the balloon due to backflow or incomplete deflation. Attempting to withdraw again is safe and often resolves the issue.
B. Ask the patient to bear down as the catheter is withdrawn with gentle pressure:
This may cause trauma if the balloon is not fully deflated. Not appropriate until it's confirmed that the balloon is completely empty.
C. Review the patient's chart to see how much water was inserted into the balloon:
Helpful for planning but not the immediate appropriate action. Reattempting aspiration is more time-sensitive and effective.
D. Explain to the patient that removal of the catheter may cause significant discomfort:
This does not solve the problem. The goal is to remove the catheter safely and with minimal discomfort.

A. Request an order for a urinalysis with culture and sensitivity:
There is no indication of infection (e.g., no cloudy urine, odor, or fever), so a C&S is not warranted at this point.

B. Irrigate the patient’s catheter using 60 mL of sterile normal saline:
Irrigation should only be done with a provider’s order or if there is a clear obstruction, which is not the case here.

C. Remove the catheter immediately and notify the health care provider:
Removing without an order or plan can put the patient at risk, especially with a spinal cord injury and potential retention issues.

D. Contact the health care provider for an order to change the catheter:
Long-term indwelling catheters are typically changed every 4 to 12 weeks to reduce infection risk and ensure function. This is the safest and most appropriate next step.

A. Disconnect the drainage tube from the catheter:
This breaks the closed system and increases the risk of infection. Not appropriate.

B. Withdraw urine from the closed system drainage bag:
The urine in the bag is not fresh and may be contaminated, leading to inaccurate results.

C. Empty contents of the drainage bag into the specimen cup:
This is not a sterile method and would not provide a reliable culture result.

D. Attach a sterile syringe to the catheter port to withdraw urine:
This is the correct sterile technique for obtaining a sample from an indwelling catheter without contaminating the system.

A. Clean injection port:
This is done after clamping and before connecting the syringe to prevent introducing infection.

B. Inject prescribed solution:
Done only after the syringe is connected to the port.

C. Twist needleless syringe into port:
This ensures a secure and sterile connection before irrigation.

D. Remove clamp and allow to drain:
This step ensures the irrigant and urine can flow out properly after irrigation.

E. Clamp catheter just below specimen port:
Done early to allow retention of solution during irrigation and prevent backflow.

F. Draw up prescribed amount of sterile solution ordered:
First step—preparing the exact amount of irrigation fluid needed.

A. Betadine:
Betadine (povidone-iodine) is commonly used for cleansing the perineal area. Patients may have an allergy to iodine-based antiseptics.

B. Shellfish:
A shellfish allergy may indicate a sensitivity to iodine, which is found in Betadine. While this connection is debated, many protocols still recommend caution.

C. Latex:
Many catheters and gloves are made with latex, which can cause serious allergic reactions, including anaphylaxis.

D. Silicone:
Silicone is hypoallergenic and usually used for patients with latex allergies. True silicone allergies are rare.

E. Tape:
Tape is used to secure the catheter tubing. Some patients have adhesive allergies that can cause skin irritation or blisters.

A. Growing urine cultures for up to 12 hours:
Nurses do not grow cultures; lab personnel handle this. The nurse’s role is collection and proper transport of specimens.

B. Labeling all specimens with date, time, and initials:
Correct labeling ensures proper identification and prevents errors in diagnosis and treatment.

C. Allowing the patient adequate time and privacy to void:
Respecting patient privacy encourages accurate specimen collection and maintains dignity.

D. Wearing gown, gloves, and mask for all specimen handling:
Gloves are necessary, but gowns and masks are not required unless splashing or isolation precautions are involved.

E. Transporting specimens to the laboratory in a timely manner:
Delays in transport can lead to contamination or degradation of the sample, affecting test accuracy.

F. Collecting the specimen from the drainage bag of an indwelling catheter:
Urine from the drainage bag is not sterile and is not appropriate for culture. It may yield inaccurate results

A. Increasing fluid intake:
This is encouraged after catheter removal to flush the bladder and promote urination. No follow-up is needed unless overdone.

B. Dribbling of urine:
This may indicate urinary incontinence or incomplete bladder control, which requires assessment.

C. Voiding in small amounts:
Could indicate urinary retention or incomplete emptying of the bladder, requiring follow-up.

D. Voiding within 6 hours of catheter removal:
This is expected. Patients should void within 6–8 hours post removal.

E. Burning with the first couple of times voiding:
Mild burning may be expected due to urethral irritation and does not usually require follow-up unless it persists or worsens.

a. Gather supplies:
Needed after verifying the order to ensure all equipment is available for a sterile procedure.

b. Obtain urine specimen:
Done after insertion of the catheter once urine is seen in the tubing.

c. Review the physician order:
Always the first step-you must ensure there is a valid order before performing a procedure.

d. Secure the bag to leg:
This is the last step to prevent pulling on the catheter and ensure patient comfort.

e. Perform pericare:
Perineal care helps reduce the risk of infection and is done before insertion.

A. Perform catheter care twice a day:
Routine perineal care and cleaning of the catheter insertion site are evidence-based practices to reduce CAUTI risk.

B. Replace the catheter on a routine basis:
Routine replacement is done, but not more effective than good hygiene in reducing infection risk. Over-manipulation may increase risk.

C. Administer cranberry tablets three times a day:
Cranberry products have not consistently shown a reduction in CAUTIs in catheterized patients.

D. Administer prophylactic antibiotics twice a day for the duration of the catheter:
This promotes antibiotic resistance and is not recommended unless there is an active infection.