Page 2518 - Saunders Comprehensive Review For NCLEX-RN

buttocks.
b. Don sterile gloves using sterile technique.
c. Pick up fenestrated drape from tray. Allow it to unfold without
touching nonsterile surface. Apply drape over perineum, exposing
labia or penis.
d. While maintaining sterility, open packet of lubricant and squeeze out
on sterile field. Lubricate catheter tip by dipping it into water-soluble
gel, 2.5 to 5 cm (1 to 2 inches) for women and 12.5 to 17.5 cm (5 to 7
inches) for men. Attach prefilled syringe to balloon port. Prepare
cotton balls or swab sticks for cleansing perineal area.
e. Remember with a sterile technique, the sterile field and gloved hands
must be maintained above the level of the waist, the 1-inch (2.5 cm)
border on the field is considered contaminated, and the nurse cannot
turn her or his back to the field at any time.
f. Catheter insertion
Female: The female should be positioned in a dorsal
recumbent position with the legs open to allow for full
visualization and maintenance of the sterile field. With
nondominant hand, fully expose urethral meatus by
spreading labia, taking care to not allow the labia to close.
Using forceps in sterile dominant hand, pick up cotton
ball or swab sticks saturated with antiseptic solution,
wiping from front to back (from clitoris toward anus).
Using a new cotton ball or swab for each area you clean,
wipe far labial fold, near labial fold, and directly over
center of urethral meatus. Pick up and hold catheter 7.5 to
10 cm (3 to 4 inches) from catheter tip. Advance catheter a
total of 7.5 cm (3 inches) in adult or until urine flows out
of catheter end. When urine appears, advance catheter
another 2.5 to 5 cm (1 to 2 inches). Do not use force to
insert catheter.
Male: Use of square sterile drape is optional; you may apply
fenestrated drape with fenestrated slit resting over penis.
Grasp penis at shaft just below glans. (If client is not
circumcised, retract foreskin with nondominant hand.)
With dominant hand, pick up antiseptic-soaked cotton
ball with forceps or swab stick and clean penis. Move
cotton ball or swab in circular motion from urethral
meatus down to base of glans. Repeat cleaning 2 more
times, using clean cotton ball/stick each time. Pick up
catheter with gloved dominant hand and insert catheter
by lifting penis to position perpendicular to client’s body
and apply light traction. Advance catheter 17.5 to 22.5 cm
(7 to 9 inches) in adult or until urine flows out of catheter
end. Advance an additional 2.5 to 5 cm (1 to 2 inches)
after urine appears. Lower penis and hold catheter
securely in nondominant hand.
8. Inflate balloon fully per manufacturer’s directions and gently pull back on the

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