A nurse is preparing to remove a patient’s urinary catheter.
After performing hand hygiene, what should the nurse do next?

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 B

Choice A rationale:

Positioning the client supine is not the immediate next step after performing hand hygiene when preparing to remove a patient’s urinary catheter. While it is important to ensure the patient is in a comfortable and appropriate position for the procedure, the immediate next step should be focused on ensuring the area is clean to prevent infection.

Choice B rationale:

After performing hand hygiene, the nurse should cleanse the perineal area with an antiseptic. This is to ensure that the area is clean before proceeding with the removal of the urinary catheter. It helps to prevent the introduction of bacteria into the urinary tract, which could lead to a urinary tract infection. The use of an antiseptic is recommended to kill any potential pathogens that may be present.

Choice C rationale:

Deflating the balloon halfway and then pulling out the catheter is not the immediate next step after performing hand hygiene. This step is usually done later in the process. Before deflating the balloon, it is important to ensure that the area is clean to prevent infection. Moreover, deflating the balloon halfway could potentially cause discomfort or injury to the patient. The balloon should be fully deflated before the catheter is removed.

Choice D rationale:

Having the client bear down during removal is not the immediate next step after performing hand hygiene. This action might be suggested during the actual removal of the catheter to aid in the process, but it is not the immediate next step. The focus right after hand hygiene should be on cleaning the area to prevent infection.

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Correct Answer is B

Explanation

Choice A rationale:

A respiratory rate of 28/min is not an indication that the intervention was effective. A normal respiratory rate for an adult at rest is between 12 and 20 breaths per minute. A respiratory rate of 28/min is considered tachypnea, which could be a sign of respiratory distress, not an improvement.

Choice B rationale:

Pink mucous membranes are a good sign. They indicate effective oxygenation and perfusion. When the body is receiving an adequate amount of oxygen, the skin, lips, and mucous membranes can appear pink. This is a positive outcome of oxygen therapy for hypoxia.

Choice C rationale:

A heart rate of 110/min is not an indication that the intervention was effective. A normal resting heart rate for adults ranges from 60 to 100 beats per minute. A heart rate of 110/min is considered tachycardia, which could be a sign of distress or compensation for hypoxia, not an improvement.

Choice D rationale:

Restlessness is not an indication that the intervention was effective. On the contrary, restlessness can be a sign of inadequate oxygenation. When the brain does not receive enough oxygen, a patient can become restless or anxious. Therefore, restlessness is not a positive outcome of oxygen therapy for hypoxia.

A. Don sterile gloves before inserting the indwelling urinary catheter. B. Apply an oil-based lubricant to the indwelling urinary catheter. C. Test the balloon on the indwelling urinary catheter before insertion. D. Use one cotton swab to clean the patient’s urinary meatus.

Correct Answer is A

Explanation

The correct answer is Choice A: Don sterile gloves before inserting the indwelling urinary catheter.

Choice A rationale:

Donning sterile gloves is crucial to prevent infection during the insertion of an indwelling urinary catheter. Maintaining aseptic technique is essential to avoid introducing pathogens into the urinary tract.

Choice B rationale:

Applying an oil-based lubricant to the catheter is not recommended as it can interfere with the sterility of the procedure and potentially cause irritation or infection.

Choice C rationale:

Testing the balloon before insertion is important, but it is not the first step in the process. The priority is to ensure that the nurse is using sterile gloves to maintain aseptic technique.

Choice D rationale:

Using one cotton swab to clean the patient’s urinary meatus is not sufficient for proper aseptic technique. The area should be cleaned thoroughly with appropriate antiseptic solutions and sterile supplies.

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A nurse is preparing to remove a patient’s urinary catheter. After performing hand hygiene, what should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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A nurse is preparing to remove a patient’s urinary catheter.
After performing hand hygiene, what should the nurse do next?