A nurse is preparing to remove an indwelling urinary catheter from a client. In what order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Slowly pull the catheter out of urethral canal.
Don clean gloves.
Withdraw the solution from the balloon.
Dry the perineal area.
Attach the syringe to the balloon injection port.
The Correct Answer is B,E,C,A,D
B. Don clean gloves: The nurse should first don clean gloves to ensure proper hygiene and to reduce the risk of infection during the procedure. This protects both the client and the nurse from any potential contamination.
E. Attach the syringe to the balloon injection port: After gloves are on, the next step is to attach the syringe to the balloon injection port of the catheter. This is the part where sterile fluid (usually saline) was used to inflate the balloon that keeps the catheter in place.
C. Withdraw the solution from the balloon: Once the syringe is attached, the nurse slowly withdraws the fluid from the balloon. This is necessary to deflate the balloon, which allows the catheter to be removed easily and without causing injury to the urethral canal.
A. Slowly pull the catheter out of urethral canal: After the balloon is deflated, the nurse gently and slowly pulls the catheter out of the urethral canal. This should be done carefully to avoid causing trauma to the urethra and surrounding tissues. The catheter should be removed in a smooth, controlled motion.
D. Dry the perineal area: After the catheter is removed, the nurse should clean and dry the perineal area to ensure hygiene. This step helps prevent skin irritation and infection after the catheter removal, ensuring that the area is properly cared for and free of moisture.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Let me clarify that you want the medication given gid, correct?": When receiving a telephone prescription, it is essential to clarify any unclear aspects of the order, such as the dosage frequency. This ensures that the prescription is accurately understood and implemented and helps prevent medication errors.
B. "Will you please spell the name of that medication for me?": Although confirming the medication name is important, it is more critical to clarify the specific directions for administering the medication, such as the frequency, rather than spelling.
C. "I will sign my name now and leave a space for you to sign your name.": Offering to leave a space for the provider's signature is standard practice. However, it's not the most critical communication safety check during the verbal order itself.
D. "Let me provide you with the client's medical record number for identification.": While important for ensuring correct patient identification, the nurse should first focus on accurately obtaining the medication prescription and other critical details before providing identification information.
Correct Answer is A
Explanation
A. Set the suction device to 120 mm Hg: For nasopharyngeal suctioning in adults, the suction pressure should typically be set between 100 and 120 mm Hg to prevent injury to the mucous membranes while effectively clearing secretions.
B. Apply suction to the catheter during insertion: Suction should not be applied during insertion of the catheter, as this can cause trauma to the mucous membranes. Suctioning should only occur when the catheter is in the appropriate position and being withdrawn.
C. Have the client tuck his chin to his chest during suctioning: The client should not tuck the chin to the chest during suctioning. Instead, the client should be asked to either cough or breathe normally. Tucking the chin may obstruct the airway and make suctioning difficult.
D. Apply a petroleum-based lubricant to the catheter: Petroleum-based lubricants should not be used as they can cause a fire hazard when oxygen is present. Instead, a water-soluble lubricant should be applied to the catheter if needed.
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