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Question

Difficulty: MediumReduction of Risk Potential

A practical nurse (PN) is preparing to remove an indwelling urinary catheter from an adult female client. Arrange the following actions in the correct sequence to reduce the risk of trauma and potential complications.

  1. 1Position the client supine with knees flexed and place a waterproof pad under the buttocks.
  2. 2Attach a designated syringe to the catheter's balloon inflation port.
  3. 3Withdraw the entire volume of sterile water from the balloon.
  4. 4Instruct the client to take a deep breath and exhale while smoothly withdrawing the catheter.
  5. 5Inspect the catheter tip to ensure it is completely intact.

Answer

The correct sequence is: position the client and place a pad, attach the syringe to the port, withdraw all fluid from the balloon, instruct the client to exhale while withdrawing the catheter, and finally inspect the catheter tip.
The correct sequence ensures client comfort, prevents environmental contamination, and minimizes the risk of urethral trauma or retained foreign bodies. Proper preparation, complete balloon deflation, and post-removal inspection are key risk reduction strategies.

Step-by-Step Solution

1
Position the client supine with knees flexed and place a waterproof pad under the buttocks.
The client is appropriately positioned, and the environment is protected.
Optimal visualization of the meatus and protection of bed linens are necessary first steps.
2
Attach a designated syringe to the catheter's balloon inflation port.
The syringe is securely connected.
A secure connection is required to draw back the fluid anchoring the catheter.
3
Withdraw the entire volume of sterile water from the balloon.
The balloon is completely deflated.
Failing to remove all fluid before pulling will cause significant urethral trauma and pain.
4
Instruct the client to take a deep breath and exhale while smoothly withdrawing the catheter.
The catheter is safely removed from the urethra.
Exhaling relaxes the pelvic floor sphincter muscles, reducing resistance during removal.
5
Inspect the catheter tip to ensure it is completely intact.
The tip is verified to be whole.
A retained catheter fragment can lead to bladder infection, obstruction, or calculi formation.

Key Concept

Indwelling Urinary Catheter Removal Sequence
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Topics

Reduction of Risk Potential

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