A patient with an indwelling urinary catheter has been given a bed bath by a new nursing assistant. The nurse evaluating the cleanliness of the patient notices crusting at the urinary meatus. The best next action of this nurse is to
a. Ask the nursing assistant to observe while the nurse performs catheter care.
b. Leave the room and ask the nursing assistant to go back and perform proper catheter care.
c. Discontinue the catheter.
d. Document the incident in the patient's chart.
ANS: A
Because the nursing assistant is new, it is best for the nurse to perform catheter care while the assistant observes. This action will ensure that the assistant has been shown the proper way to perform the task and fosters collaboration rather than leaving the room just to tell the assistant to come back. While the nurse is in the room, the nursing assistant should perform the task. Discontinuing the catheter is not warranted and requires a physician's order. This occurrence does not need to be documented in the patient's chart, granted no harm has come to the patient.
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