The charge nurse is observing a newly licensed nurse catheterize an older adult client admitted with an enlarged prostate. Which action by the newly licensed nurse requires intervention from the charge nurse?
A) The newly licensed nurse injects 10 mL of 2% lidocaine gel into the client's urethra.
B) The newly licensed nurse inserts a 16 French coudé-tipped catheter.
C) The newly licensed nurse clamps the catheter after draining 500 mL.
D) The newly licensed nurse clamps the catheter after draining 800 mL.
Answer: D
Draining 800 mL before clamping might cause a vasovagal response, so the charge nurse would need to intervene. Using 2% lidocaine gel 10 mL injected into the male urethra reduces discomfort during catheterization and the risk of catheter-associated infection, and it promotes pelvic muscle relaxation. A coudé-tipped catheter is passed more easily in the older man with an enlarged prostate. Some clients experience a vasovagal response, becoming pale, sweaty, and hypotensive, if the bladder is rapidly drained. Draining urine in 500 mL increments and clamping the catheter for 5-10 minutes between increments may prevent this response.
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