A nurse is removing an indwelling urinary catheter. Which of the following actions is appropriate?

SCTIMST Staff Nurse - 2015 (Set-B)

Fundamental of Nursing

Easy

Appeared in: SCTIMST Staff Nurse - 2015 (Set-B)

Explanation

Documenting the time of removal is a crucial nursing action as it establishes the baseline for monitoring the patient's urinary function.
This documentation is essential for tracking the time until the patient's first void, which should typically occur within 6-8 hours.
Failure to void within this timeframe may indicate urinary retention, a common complication that requires further assessment and intervention.
Accurate documentation is also a legal requirement and a key component of the patient's medical record.

Option A: Catheter removal is a clean procedure, not a sterile one. Therefore, clean (non-sterile) gloves are sufficient. Using sterile gloves is unnecessary and not cost-effective.
Option B: Cutting the balloon lumen is a dangerous and incorrect action. It can cause the balloon to not deflate completely, leading to urethral trauma upon removal. It also risks leaving fragments of the catheter inside the bladder.
Option D: The standard and most effective position for catheter removal in both males and females is the supine or dorsal recumbent position. This allows for clear visualization and access to the perineal area.

Clinical Relevance

Nursing practice connection: Knowing The concept tested is the correct and safe procedure for removing an indwelling urinary catheter, which is a fundamental nursing skill helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
The primary clinical concern after catheter removal is ensuring the patient can void independently and does not develop urinary retention.
Documenting the removal time is a critical patient safety measure. It initiates the 'voiding trial' period, where nurses monitor for the return of normal bladder function.
What if? If a patient has not voided 8 hours after catheter removal and complains of lower abdominal pressure, the nurse's first action should be to perform a bladder scan to assess for urinary retention. If a significant amount of urine is present, the nurse should notify the healthcare provider, as re-catheterization may be necessary.

How to Approach the Question

First, identify the core task in the question: 'removing an indwelling urinary catheter'. This is a process-based question.
Recall the standard steps for this nursing procedure. Think about preparation, the action itself, and follow-up care.
Evaluate each option against the standard of care for this procedure.
Option A (sterile gloves): Is removal a sterile or clean procedure? It's clean. So, this is incorrect.
Option B (cut the lumen): Is this safe? No, it's dangerous and can cause trauma. This is incorrect.
Option D (left side position): Is this the standard position? No, supine is standard. This is incorrect.

Concept Tested & Keywords

Concept Tested: The concept tested is the correct and safe procedure for removing an indwelling urinary catheter, which is a fundamental nursing skill.
Stem keywords: removing, indwelling urinary catheter, appropriate action
Lead-in keywords: appropriate

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E6 Nursing Fundamentals Potter Perry 12e Part 6 p. 15-17

E6 Nursing Fundamentals Taylor p. 599-601