A nurse is preparing to insert an indwelling urinary catheter for a patient.
What actions should the nurse plan to take?

Choice A rationale:

Urinary retention is a condition where the bladder doesn’t empty all the way or at all when you urinate. This can lead to leakage of urine, as the bladder is overfilled and may result in small amounts of urine escaping. This symptom is often associated with urinary retention and is therefore a likely finding in a client with this condition.

Choice B rationale:

Dark-colored urine is not typically a direct symptom of urinary retention. It can be a sign of dehydration, certain dietary factors, or a side effect of some medications. While it’s possible for a person with urinary retention to have dark-colored urine, it’s not a specific or direct symptom of the condition.

Cloudy urine can be a sign of a urinary tract infection (UTI), which can occur as a complication of urinary retention. However, it’s not a direct symptom of urinary retention itself. A nurse would not necessarily expect to see cloudy urine in a client with urinary retention unless a UTI or another complication was present.

Choice D rationale:

Blood in the urine, or hematuria, is not a typical symptom of urinary retention. It can be a sign of various conditions, including UTIs, kidney stones, or more serious conditions like bladder or kidney disease. While it’s possible for a person with urinary retention to have blood in their urine, it’s not a direct symptom of the condition.

Choice A rationale:

Collecting urine from the catheter’s port is not the correct procedure when collecting a urine specimen for culture and sensitivity through straight catheterization. The port is not a sterile environment and could contaminate the specimen, leading to inaccurate results.

Choice B rationale:

Using a sterile specimen container is the correct procedure. This ensures that the specimen is not contaminated by any external bacteria or substances, which could affect the results of the culture and sensitivity test. The container must be sterile to prevent the growth of microbes that are not present in the urine sample. This helps to ensure that the results of the culture are accurate and reflect the microbes present in the urine, not those introduced during collection.

Choice C rationale:

Inflating the balloon with sterile water is not a step in this procedure. The balloon is part of an indwelling catheter, not a straight catheter. An indwelling catheter remains in the bladder for a longer period, and the balloon is inflated to keep it in place. A straight catheter is used for a single voiding or to obtain a sterile urine specimen.

Choice D rationale:

Instructing the patient to clean from front to back with an antiseptic solution is not a step in this procedure. While maintaining cleanliness is important, this specific instruction is more relevant to a clean-catch midstream urine specimen, not a specimen collected through straight catheterization.