Nursing Procedure: Urinary Catheterization
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A nurse is preparing to implement the provider's prescription. Which of the following actions should the nurse take? Select all that apply.
Perform a surgical alcohol-based hand scrub.
Unfold the outermost flap of the kit away from the body.
Apply sterile gloves by placing the glove onto the dominant hand first.
Set up a sterile field that is level with their hips.
Hold arms over the sterile field to drop urinary catheter onto the field.
Don sterile gloves to open the top flap of the kit.
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Step by Step Written Solution
In this problem, we need to identify the correct nursing actions for implementing a sterile procedure, specifically urinary catheterization, based on clinical notes.
Sterile Technique and Catheterization
Let's look at the patient notes. The client has urinary retention with five hundred milliliters of fluid in the bladder, and the provider has likely prescribed a catheterization. This requires strict sterile technique.
Clinical Situation
- Post-op urinary retention.
- 500 mL in bladder.
- Goal: Perform sterile catheterization.
First, let's look at hand hygiene. The option mentions a surgical alcohol-based hand scrub. Since this is a bedside procedure, standard surgical scrubbing isn't required; traditional handwashing or standard alcohol-based hand rub is sufficient.
Next, let's examine the process of opening a sterile kit.
Opening a Sterile Kit
The correct technique is to unfold the outermost flap away from the body to prevent reaching over the sterile field. This action is correct.
Now, let's consider donning sterile gloves.
Gloving Technique
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