A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?
Position the client supine.
Cleanse the perineal area with an antiseptic.
Deflate the balloon halfway and then pull out the catheter.
Have the client bear down during removal.
The Correct Answer is C
Choice A reason: Positioning the client supine is not a necessary action for the nurse to take, as the client can be in any comfortable position for the catheter removal. The nurse should explain the procedure to the client and provide privacy.
Choice B reason: Cleansing the perineal area with an antiseptic is not a required action for the nurse to take, as the catheter is already sterile and the risk of infection is low. The nurse should wear gloves and use a clean syringe to deflate the balloon.
Choice C reason: Deflating the balloon halfway and then pulling out the catheter is the correct action for the nurse to take, as it ensures that the catheter is removed smoothly and without causing trauma to the urethra. The nurse should apply gentle traction and observe the urine color and amount in the drainage bag.
Choice D reason: Having the client bear down during removal is not a recommended action for the nurse to take, as it can cause discomfort and bleeding. The nurse should instruct the client to relax and breathe normally during the procedure.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Positioning the client supine is not a necessary action for the nurse to take, as the client can be in any comfortable position for the catheter removal. The nurse should explain the procedure to the client and provide privacy.
Choice B reason: Cleansing the perineal area with an antiseptic is not a required action for the nurse to take, as the catheter is already sterile and the risk of infection is low. The nurse should wear gloves and use a clean syringe to deflate the balloon.
Choice C reason: Deflating the balloon halfway and then pulling out the catheter is the correct action for the nurse to take, as it ensures that the catheter is removed smoothly and without causing trauma to the urethra. The nurse should apply gentle traction and observe the urine color and amount in the drainage bag.
Choice D reason: Having the client bear down during removal is not a recommended action for the nurse to take, as it can cause discomfort and bleeding. The nurse should instruct the client to relax and breathe normally during the procedure.
Correct Answer is B
Explanation
Choice A reason: Collecting urine from the catheter's port is not a correct action for the nurse to take, as it can introduce contamination and infection into the urinary tract. The nurse should insert a new, sterile catheter into the bladder and collect the urine directly from the catheter.
Choice B reason: Using a sterile specimen container is a correct action for the nurse to take, as it ensures that the urine sample is not contaminated by any bacteria or other substances. The nurse should label the container with the client's name, date, and time of collection and send it to the laboratory as soon as possible.
Choice C reason: Using sterile water to inflate the balloon is not a relevant action for the nurse to take, as it applies to an indwelling catheter, not a straight catheter. A straight catheter does not have a balloon and is removed after the urine is drained.
Choice D reason: Instructing the client to clean from front to back with an antiseptic solution is a good action for the nurse to take, as it helps to prevent the introduction of bacteria from the anal area into the urethra. However, it is not the best answer, as it is a general hygiene measure, not a specific action for obtaining a urine specimen.
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