NCLEX-RN
Fundamentals NCLEX RN Questions Questions
Extract:
The nurse is removing an indwelling urinary catheter
Item 1 of 1
Nurses Note
The removal of the client’s indwelling urinary catheter was attempted. Perineal hygiene was performed before the removal. The urine collection bag was emptied with 450 mL of clear, straw-colored urine. 2 mL of fluid was removed during the deflation of the balloon. Resistance was felt when the tubing was removed, and the client reported discomfort.
Question 1 of 5
Drag words from the choices below to fill the blank in the following sentence. Prior to attempting to remove the catheter again, the nurse should--------------------------
Correct Answer: D
Rationale: The amount of fluid removed from the balloon (this secures the catheter in place inside of the bladder) was inadequate. 10 mL of fluid is typically used to inflate the catheter balloon to keep it secure inside the bladder. The nurse should further deflate the catheter balloon by passively allowing the fluid to fill the syringe. The nurse may gently pull back on the syringe plunger if this does not work. By removing the residual volume, the nurse should then remove the catheter.
Cutting the balloon inflation valve would negate the closed system. Cutting the valve is not standard practice and should not be done. Positioning the client 45 degrees is not appropriate for discontinuing an indwelling urinary catheter. The correct approach for positioning a client to remove an indwelling catheter is having a male client supine and a female in the dorsal recumbent position.
Placing a warm compress over the perineum may give the client comfort, but this will not effectively troubleshoot the problem with the catheter. The issue is not with a bladder spasm, yet an indwelling urinary catheter that has not been entirely deflated.
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