The nurse has completed closed irrigation of a client’s retention cath

The nurse has completed closed irrigation of a client’s retention catheter. What specific information should the nurse document about this procedure?

1. Number of ml of solution used to inflate the balloon of the catheter
2. Abnormal drainage, such as blood clots, pus, or mucous shreds
3. Location of the draining bag
4. Technique used to conduct the irrigation

ANSWER

Correct Answer: 2
Rationale 1: The nurse does not need to document the number of ml of solution used to inflate the balloon of the catheter, as the catheter already was in place.
Rationale 2: The nurse should note any abnormal constituents, such as blood clots, pus, or mucous shreds.
Rationale 3: The nurse does not need to document the location of the drainage bag.
Rationale 4: The nurse does not need to document the technique used to conduct the irrigation.