Difficulty: Medium
Average Score: 70%
Simulated
A charge nurse is observing a newly-licensed nurse insert an indwelling urinary catheter for a male client. Which of the following actions by the newly-licensed nurse requires intervention by the charge nurse?
Correct answer
B
Rationale
Correct Answer: B. Pulls gently on the catheter to check for resistance after inflating the balloon.
Rationale: Pulling on the catheter after inflating the balloon can cause trauma to the urethra or bladder. This action is unnecessary and can lead to complications such as bleeding or dislodging the catheter. It is important to secure the catheter properly and avoid unnecessary manipulation.
Summary of other choices:
A: Dons sterile gloves before cleaning the client's meatus - Correct practice to maintain aseptic technique.
C: Secures the tubing to the client's upper thigh - Proper technique for securing the catheter.
D: Lubricates the first 2.5 to 5 cm (2 in) of the catheter - Correct practice to facilitate insertion and reduce discomfort for the client.
Rationale: Pulling on the catheter after inflating the balloon can cause trauma to the urethra or bladder. This action is unnecessary and can lead to complications such as bleeding or dislodging the catheter. It is important to secure the catheter properly and avoid unnecessary manipulation.
Summary of other choices:
A: Dons sterile gloves before cleaning the client's meatus - Correct practice to maintain aseptic technique.
C: Secures the tubing to the client's upper thigh - Proper technique for securing the catheter.
D: Lubricates the first 2.5 to 5 cm (2 in) of the catheter - Correct practice to facilitate insertion and reduce discomfort for the client.