A nurse in an outpatient mental health clinic is caring for a client. Select the 3 findings that require immediate follow-up.

• A is incorrect because diarrhea is not an adverse effect of clonidine, but rather a symptom of other conditions such as infection, inflammation, or food intolerance.
• B is correct because dry mouth is a common adverse effect of clonidine, which is an alpha-2 adrenergic agonist that reduces sympathetic nervous system activity.
• C is incorrect because photophobia, or sensitivity to light, is not an adverse effect of clonidine, but rather a symptom of other conditions such as migraine, eye injury, or infection.
• D is incorrect because bruising, or bleeding under the skin, is not an adverse effect of clonidine, but rather a symptom of other conditions such as coagulation disorders, vitamin deficiency, or trauma.

Choice A rationale:

Attaching a prefilled syringe to the catheter inflation hub is a step performed after the catheter insertion to inflate the balloon, securing the catheter in the bladder. This action is not the first step and should not be done before cleansing the meatus and positioning the sterile drape.

Choice B rationale:

Positioning the sterile drape leaving the perineum exposed is a necessary step in maintaining the sterility of the procedure area. However, it is not the first action the nurse should take. Cleaning the client's meatus with an antiseptic solution is the initial step to prevent infection during catheter insertion.

Choice C rationale:

Cleaning the client's meatus with antiseptic solution is the first step in inserting an indwelling urinary catheter. This action helps to reduce the risk of urinary tract infection by minimizing the introduction of bacteria into the urethra.

Choice D rationale:

Lubricating the catheter with water-soluble gel is a step performed after cleansing the meatus and positioning the sterile drape. It facilitates the smooth insertion of the catheter into the urethra. However, it is not the first action to be taken.