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.
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Related Questions
Correct Answer is D
Explanation
A. The Emergency Medical Treatment and Active Labor Act requires that emergency care be provided regardless of the client’s behavior, as long as the client is seeking treatment for an emergency medical condition.
B. EMTALA requires that a client receive a medical screening and stabilization before being transferred, regardless of whether the condition is terminal. A terminal diagnosis does not justify transferring a client without stabilization first.
C. EMTALA prohibits discrimination based on a client’s ability to pay. A client cannot be transferred or discharged from an emergency department based on their inability to pay for services.
D. EMTALA requires that a client must be stabilized before being transferred to another facility. This ensures that the client is not placed at risk by the transfer, and the new facility is prepared to manage their care appropriately.
Correct Answer is B
Explanation
A. Notify the housekeeping department: Housekeeping is not the appropriate department to address a malfunctioning infusion pump. The nurse should take immediate action to address the malfunction, such as replacing the pump.
B. Replace the infusion pump: If the infusion pump is malfunctioning, the nurse should replace it with a functional one to ensure that the client's infusion continues safely. This is the most appropriate and immediate action to take in response to a malfunction.
C. Check the expiration date on the safety inspection sticker: While it is important to ensure equipment is regularly inspected, checking the expiration date on the safety inspection sticker does not address an immediate malfunction. The priority should be replacing the pump to prevent disruption of the IV infusion.
D. Plug the infusion pump into a grounded outlet: While ensuring that the pump is plugged into a grounded outlet is important for electrical safety, this does not directly resolve the issue if the pump itself is malfunctioning.
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