A nurse is performing a bladder irrigation for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?
A.
Slowly instill 400 to 500 mL of the prescribed solution.
B.
Clamp the drainage tubing distal to the injection port.
C.
Use a syringe with a 19-gauge needle.
D.
Withdraw the irrigation solution into the syringe.
The Correct answer and Explanation is:
The correct answer is A. Slowly instill 400 to 500 mL of the prescribed solution.
Explanation:
Bladder irrigation is a procedure performed to maintain patency in an indwelling urinary catheter and to prevent or treat complications such as blood clots or infection. It is important to follow proper techniques to ensure patient safety and effectiveness of the procedure.
Option A: Slowly instill 400 to 500 mL of the prescribed solution. This is the correct approach. The volume of irrigation solution is typically between 400 to 500 mL, depending on the protocol established by the healthcare provider. Instilling the solution slowly helps to prevent bladder distension and discomfort. It allows for gradual filling and helps to ensure that the solution effectively flushes out any debris or clots in the bladder.
Option B: Clamp the drainage tubing distal to the injection port. This option is incorrect because clamping the drainage tubing can lead to bladder distension or pressure. The drainage should remain open to allow for proper flow and to avoid complications such as urinary retention.
Option C: Use a syringe with a 19-gauge needle. This option is also incorrect. While a large gauge needle might be appropriate for certain procedures, the typical syringe used for bladder irrigation does not require a needle of this size. Instead, a catheter tip syringe (without a needle) is commonly utilized for irrigation.
Option D: Withdraw the irrigation solution into the syringe. This option is misleading. During bladder irrigation, the nurse instills the solution into the bladder rather than withdrawing it. The solution should be pre-measured and then instilled directly to irrigate the bladder.
In summary, option A is the appropriate action for bladder irrigation, ensuring the safety and comfort of the patient while effectively maintaining catheter patency.