The nurse is discontinuing the patient's indwelling urinary catheter. The catheter is not easily withdrawn after the balloon is deflated. Which is the appropriate nursing action?

Reattach the syringe and attempt to withdraw more water from the balloon.

Ask the patient to bear down as the catheter is withdrawn with gentle pressure.

Review the patient's chart to see how much water was inserted into the balloon.

Explain to the patient that removal of the catheter may cause significant discomfort.

Answer and Explanation

The Correct Answer is A

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B. Ask the patient to bear down as the catheter is withdrawn with gentle pressure: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.

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Correct Answer is C

Explanation

A. An assessment of a client experiencing chest pain:
Assessments require clinical judgment and must be performed by a licensed nurse.

B. An admission assessment on a newly admitted patient:
Initial assessments are a RN responsibility and cannot be delegated.

C. Vital signs on a client that is ready for discharge:
CNAs can take routine vital signs. The nurse will still interpret them before discharge.

D. Administration of oral medications:
Medication administration must be performed by a licensed nurse or medication aide depending on state laws.

A. Clean injection port. B. Inject prescribed solution. C. Twist needleless syringe into port. D. Remove clamp and allow to drain. E. Clamp catheter just below specimen port. F. Draw up prescribed amount of sterile solution ordered.

Correct Answer is F,E,A,C,B,D

Explanation

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

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

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

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

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

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

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The nurse is discontinuing the patient's indwelling urinary catheter. The catheter is not easily withdrawn after the balloon is deflated. Which is the appropriate nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is F,E,A,C,B,D

Explanation

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