No urine in the urethra. What should the nurse do?
Throw the catheter way and begin again.
Fill the balloon with the recommended sterile water.
Remove the catheter, wipe with alcohol, and reinsert after lubrication.
Leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter.
The Correct Answer is D
A. Throw the catheter away and begin again:
While starting again is necessary, this choice omits using the first catheter as a landmark, which helps prevent repeated misplacement.
B. Fill the balloon with the recommended sterile water:
The balloon should never be inflated unless urine flow is observed, confirming placement in the bladder.
C. Remove the catheter, wipe with alcohol, and reinsert after lubrication:
Once contaminated, the catheter must not be reused. Alcohol cleaning does not sterilize it.
D. Leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter:
This is the correct nursing action. It prevents repeated misplacement by using the misplaced catheter as a guide.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Do not give the medication:
Nurses should never administer medications prepared by someone else, as this violates the “right medication” and “right patient” principles.
B. Administer the medication just this once:
Even a one-time exception is unacceptable and compromises patient safety and nurse accountability.
C. Give the medication for any pain score greater than 8:
This does not address the issue of medication verification and safety.
D. Avoid the issue and pretend to not hear the request:
This is unprofessional. The nurse should actively refuse and explain the rationale.
Correct Answer is D
Explanation
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.
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