A client had an indwelling urinary catheter placed for surgery yesterday. The client is now awake, ambulating, and voiding is expected. Which action best reduces infection risk?
1Irrigate the catheter with sterile saline every 2 hours.
2Clamp the catheter for 8 hours prior to removal to prevent infection.
3Remove the catheter promptly if there is no ongoing indication.✓ Correct answer
4Maintain the catheter until the client requests its removal.
Explanation
The most effective way to reduce catheter-associated infection risk is to avoid unnecessary catheter use and remove the catheter promptly when it is no longer indicated. Routine irrigation, prolonged use for convenience, or clamping does not reduce infection risk.
Clinical Judgment Use the client cues, timing, labs, and safety risks to select the response that best fits Prompt catheter removal.
Memory Tip Match the strongest cue cluster to the safest nursing judgment.
KR vs US NCLEX items reward cue-based priority thinking rather than isolated recall.
Clinical Practice GuideFor Prompt catheter removal, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.
CautionDo not choose an action from one isolated cue when the full scenario changes priority or safety.
Device Necessity — The ongoing clinical reason for keeping an invasive device in place.
Indwelling Catheter — A urinary catheter that remains in the bladder for continuous drainage.
Prompt Removal — Removing a device as soon as it is no longer clinically needed.