The charge nurse is observing a newly licensed nurse catheterize an older adult client admitted with an enlarged prostate.Which action by the newly licensed nurse requires intervention from the charge nurse?

Question

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A) Draining 800 mL before clamping might cause a vasovagal response, so the charge nurse would need to intervene. Using 2% lidocaine gel 10 mL injected into the male urethra reduces discomfort during catheterization and the risk of catheter-associated infection, and it promotes pelvic muscle relaxation. A coudé-tipped catheter is passed more easily in the older man with an enlarged prostate. Some clients experience a vasovagal response, becoming pale, sweaty, and hypotensive, if the bladder is rapidly drained. Draining urine in 500 mL increments and clamping the catheter for 5-10 minutes between increments may prevent this response.
B) Draining 800 mL before clamping might cause a vasovagal response, so the charge nurse would need to intervene. Using 2% lidocaine gel 10 mL injected into the male urethra reduces discomfort during catheterization and the risk of catheter-associated infection, and it promotes pelvic muscle relaxation. A coudé-tipped catheter is passed more easily in the older man with an enlarged prostate. Some clients experience a vasovagal response, becoming pale, sweaty, and hypotensive, if the bladder is rapidly drained. Draining urine in 500 mL increments and clamping the catheter for 5-10 minutes between increments may prevent this response.
C) Draining 800 mL before clamping might cause a vasovagal response, so the charge nurse would need to intervene. Using 2% lidocaine gel 10 mL injected into the male urethra reduces discomfort during catheterization and the risk of catheter-associated infection, and it promotes pelvic muscle relaxation. A coudé-tipped catheter is passed more easily in the older man with an enlarged prostate. Some clients experience a vasovagal response, becoming pale, sweaty, and hypotensive, if the bladder is rapidly drained. Draining urine in 500 mL increments and clamping the catheter for 5-10 minutes between increments may prevent this response.
D) Draining 800 mL before clamping might cause a vasovagal response, so the charge nurse would need to intervene. Using 2% lidocaine gel 10 mL injected into the male urethra reduces discomfort during catheterization and the risk of catheter-associated infection, and it promotes pelvic muscle relaxation. A coudé-tipped catheter is passed more easily in the older man with an enlarged prostate. Some clients experience a vasovagal response, becoming pale, sweaty, and hypotensive, if the bladder is rapidly drained. Draining urine in 500 mL increments and clamping the catheter for 5-10 minutes between increments may prevent this response.

The Charge Nurse Is Observing a Newly Licensed Nurse Catheterize