The nurse is assigned to care for a hospitalized confused client with an indwelling urinary catheter. On entering the client's room, the nurse notes the client pulling at the catheter and grimacing in pain. Blood is trickling from the client's meatus and the urine in the drainage bag is pink. Which action should the nurse take first?

Question

Quizplus · Accepted Answer

Because signs of traumatic injury are present, the nurse should follow steps to remove the catheter before further complications such as obstruction occur. Steps for removing an indwelling catheter include the following: Perform hand hygieneEnsure privacy and explain the procedure to the clientApply clean glovesPlace a waterproof pad underneath the clientRemove any adhesive tape or device anchoring the catheterFollow specific manufacturer instructions for balloon deflationLoosen the syringe plunger and connect the empty syringe hub into the inflation portDeflate the balloon by allowing water to flow back into the syringe naturally, removing all 10 mL, or applicable amount (note the size of the balloon labeled on the balloon port). If water does not flow back naturally, use only gentle aspiration.Remove the catheter gently and slowly; inspect to make sure it is intact and fragments were not left in the client.If any resistance is met, stop the removal procedure and consult with the urologist for removalEmpty and measure urine before discarding the catheter and drainage bag in the biohazard bin or according to hospital policyRemove gloves and perform hand hygiene Perform hand hygiene Ensure privacy and explain the procedure to the client Apply clean gloves Place a waterproof pad underneath the client Remove any adhesive tape or device anchoring the catheter Follow specific manufacturer instructions for balloon deflation Loosen the syringe plunger and connect the empty syringe hub into the inflation port Deflate the balloon by allowing water to flow back into the syringe naturally, removing all 10 mL, or applicable amount (note the size of the balloon labeled on the balloon port). If water does not flow back naturally, use only gentle aspiration. Remove the catheter gently and slowly; inspect to make sure it is intact and fragments were not left in the client. If any resistance is met, stop the removal procedure and consult with the urologist for removal Empty and measure urine before discarding the catheter and drainage bag in the biohazard bin or according to hospital policy Remove gloves and perform hand hygiene (Option A) A urine specimen can be collected after the balloon is deflated or after the catheter is removed if needed. (Option D) The meatus should be cleaned after balloon deflation. Educational objective: When the urinary catheter balloon occludes the urethra, it should be deflated immediately to prevent further injury or complication. After balloon deflation, gently and slowly remove the catheter. If there is resistance, notify the urologist.

The Nurse Is Assigned to Care for a Hospitalized Confused