Which nursing intervention is appropriate when caring for a client wit

Which nursing intervention is appropriate when caring for a client with a retention catheter?

1. Don sterile gloves.
2. Gently retract the labia majora away from the urinary meatus.
3. Observe urine in the drainage bag.
4. Retape the catheter to the thigh.

ANSWER

Correct Answer: 4
Rationale 1: Gloves are to be worn for cleaning but not sterile gloves.
Rationale 2: When giving catheter care to a female, the labia minora is gently retracted away from the urinary meatus, not the labia majora.
Rationale 3: The urine in the tubing should be observed, not the urine in the bag. Observing the urine in the tubing promotes accurate assessment of urine.
Rationale 4: Retaping the catheter to the thigh after care is given prevents trauma and pain from tension and pulling.