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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A reason: Leakage of urine is a sign of urinary retention, as it indicates that the bladder is overdistended and unable to empty completely. The urine may leak around the urethra or through a catheter.

Choice B reason: Dark-colored urine is not a sign of urinary retention. It can be caused by dehydration, certain foods or medications, or liver or kidney problems.

Choice C reason: Cloudy urine is not a sign of urinary retention. It can be caused by infection, inflammation, or stones in the urinary tract.

Choice D reason: Blood in urine is not a sign of urinary retention. It can be caused by trauma, infection, cancer, or coagulation disorders in the urinary tract.

A. You should expect your stoma to be a purple color. B. Your colostomy will not produce formed stool. C. The end of the stoma will be painful after this procedure. D. You will have a stoma in your left lower abdomen.

Correct Answer is D

Explanation

Choice A reason: You should not expect your stoma to be a purple color. A purple stoma indicates ischemia or necrosis, which are serious complications that require immediate medical attention. A healthy stoma should be pink or red and moist.

Choice B reason: Your colostomy will produce formed stool, depending on the location of the colostomy. A sigmoid colostomy is located in the lower part of the large intestine, where most of the water is absorbed from the stool. Therefore, the stool from a sigmoid colostomy will be more solid and regular than from other types of colostomies.

Choice C reason: The end of the stoma will not be painful after this procedure. The stoma is made from the lining of the intestine, which does not have nerve endings that sense pain. However, the skin around the stoma may be sore or irritated from the surgery or the appliance.

Choice D reason: You will have a stoma in your left lower abdomen. A sigmoid colostomy is created by bringing the end of the sigmoid colon, which is the last segment of the large intestine, through an opening in the left lower quadrant of the abdomen. The stoma is then attached to the skin and covered with an appliance that collects the stool.

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A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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