The patient has a catheter that must be irrigated. The nurse is using a needleless closed irrigation technique. In which order will the nurse perform the steps, starting with the first one?
Clean injection port.
Inject prescribed solution.
Twist needleless syringe into port.
Remove clamp and allow to drain.
Clamp catheter just below specimen port.
Draw up prescribed amount of sterile solution ordered.
The Correct Answer is F,E,A,C,B,D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. “Do you want daily weights on this patient?”
Daily weights may be useful in fluid management, but they are not a priority for CAUTI prevention or catheter care.
B. “Will the patient be able to return home?”
Discharge planning is important, but this is not the most immediate or clinically relevant concern for the nurse during rounds.
C. “Can we discontinue the indwelling catheter?”
Indwelling catheters significantly increase the risk of urinary tract infections, especially in vulnerable patients like those who are confused or already battling pneumonia. Removing the catheter as soon as it's no longer medically necessary is a key step in preventing further complications.
D. “Should we get another chest x-ray today?”
A follow-up chest x-ray may be considered based on clinical need, but it is not the nurse's priority in relation to catheter care.
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.
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