The nurse has completed closed irrigation of a client's retention ...

[wenmo]

The nurse has completed closed irrigation of a client's retention catheter. What specific information should the nurse document about this procedure?
 
  1. Number of ml of solution used to inflate the balloon of the catheter
  2. Abnormal drainage, such as blood clots, pus, or mucous shreds
  3. Location of the draining bag
  4. Technique used to conduct the irrigation

Question 2

A UAP has applied a condom catheter to a client. The nurse should document what information about this procedure?
 
  1. Number of ml of fluid used to inflate the balloon
  2. Location of the drainage bag
  3. Name of the UAP who applied the device
  4. Time and date that the condom catheter was applied
  5. Integrity of the penis

[Rilsmarie951]

Answer to Question 1

Correct Answer: 2
Rationale 1: The nurse does not need to document the number of ml of solution used to inflate the balloon of the catheter, as the catheter already was in place.
Rationale 2: The nurse should note any abnormal constituents, such as blood clots, pus, or mucous shreds.
Rationale 3: The nurse does not need to document the location of the drainage bag.
Rationale 4: The nurse does not need to document the technique used to conduct the irrigation.

Answer to Question 2

Correct Answer: 4, 5
Rationale 1: A condom catheter does not have a balloon that needs to be inflated.
Rationale 2: The nurse does not need to document the location of the drainage bag.
Rationale 3: The nurse does not need to document the name of the UAP who applied the device.
Rationale 4: The nurse should document the application of the condom, including the time.
Rationale 5: The nurse should document any pertinent observations, such as the integrity of the penis.