The nurse is initiating closed continuous bladder irrigation using a three-way catheter. Prior to beginning the flow of the irrigation fluid, which action by the nurse is the most appropriate?

Question

1. Opening the roller clamp to the desired flow rate
2. Emptying the urine collection bag
3. Documenting the procedure
4. Assessing the drainage for amount, color, and clarity

Answer 1

Correct Answer: 2

Prior to beginning irrigation, the nurse should empty the collection bag and record the output on the client's intake and output record. The roller clamp is opened when beginning irrigation, and the output drainage is then assessed for amount, color, and clarity. After initiating the procedure, the nurse documents the irrigation.