QLexNursing

First Action :Clean the urethral meatus with antiseptic.

✨Cleaning the urethral meatus with antiseptic is the first step after donning sterile gloves because it significantly reduces the number of microorganisms at the insertion site.

✨This action helps prevent catheter-associated urinary tract infections (CAUTIs), which are a major risk when inserting a urinary catheter.

✨Effective cleansing ensures that the catheter does not drag bacteria from the perineal surface into the urinary tract.

✨This step is required before touching or manipulating the catheter to maintain full sterile technique.

✨Performing antiseptic cleansing first promotes safe, infection-controlled catheterization, especially for this client who already has pneumonia and is at higher risk of infection.

Next Action: Slowly insert the catheter through the urethral meatus.

✨ After the meatus is cleaned, the sterile catheter can be gently inserted to avoid tissue trauma.

✨Slow insertion allows the nurse to monitor for resistance or discomfort, which helps prevent urethral injury.

✨The catheter must be advanced carefully to maintain sterility and ensure correct placement in the bladder.

✨This step is required before urine flow is observed and before any drainage or measurement can occur.

✨Proper and slow catheter insertion supports effective bladder emptying, especially important because this client has 480 mL of retention with a distended bladder.

“Prepare supplies within the catheterization kit.”

✨This step occurs before donning sterile gloves and before perineal cleaning, not after.

✨The supplies are already arranged once the sterile kit is opened using aseptic technique, so preparing them again at this stage would break sterility.

✨Doing this after gloves are donned risks contaminating the sterile field, increasing infection risk.

✨It interrupts the proper sequence of sterile catheterization by mixing clean and sterile actions.

✨Therefore, this is not the correct first step after perineal care and sterile glove application.

“Separate the labia.”

✨Separating the labia is performed before cleaning the urethral meatus, not after.

✨The labia must be separated prior to applying antiseptic so that the urethral opening is fully visible.

✨Doing this after donning sterile gloves is correct, but it must occur immediately before cleansing, not later in the sequence.

✨If done at the wrong time, it disrupts sterile technique and increases the risk of contaminating the area.

✨ Because cleansing comes first in this question’s sequence, this option is not the correct first action.

“Instruct the client to bear down as if they were going to void.”

✨Bearing down helps relax the pelvic floor but is done just before catheter insertion, not before cleansing.

✨If used at the wrong point, this step can cause contamination of the area due to urine leakage.

✨It does not replace the need for antiseptic cleansing, which is more important for infection control.

✨ It is an optional technique and not part of the mandatory sterile sequence required in catheterization.

✨Therefore, this is not the correct “first” action after donning sterile gloves.

“Inserting the catheter until urine flows.”

✨ This step comes after initial insertion, not immediately after donning gloves and cleansing.

✨ It indicates correct placement, but only after the catheter has already been advanced through the meatus.

✨Jumping to this step too soon would skip essential sterile practices and increase risk of trauma.

✨It must be done later in the sequence—once the catheter is already inside the urethra.

✨Therefore, it is not the next immediate action after cleansing.

“Measuring and recording urine output.”

✨This occurs only after the catheter is inserted and urine has drained, not early in the procedure.

✨Measuring output is important, especially since this client has 480 mL urinary retention, but timing matters.

✨Recording output does not contribute to sterile insertion and therefore must happen near the end of the procedure.

✨Jumping to this action too early would completely disrupt the sterile sequence.

✨Because it belongs in the final steps, it is not the correct choice here.

“Removing the catheter.”

✨In an intermittent catheterization, the catheter is removed only after the bladder is drained.

✨Removing it at this stage would prevent the nurse from completing the prescribed treatment.

✨It would leave the bladder still distended, failing to relieve the client’s discomfort or urinary retention.

✨It is completely out of order in the sterile procedure and would cause ineffective care.

✨Because removal happens last, it is never the correct step immediately after cleansing and glove use.