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ISB: Elimination
Nightingale BSN 205, Week 11, ISB: Elimination (Urinary Cath Lessons)
| Question | Answer |
|---|---|
| Which of the following demonstrate that further teaching is required to prevent an infection related to being catheterized? (Select all that apply.) | An elderly female patient carries her urinary drainage bag like a purse under her arm as she ambulates. Pt is being transferred in a wheelchair, he places the drainage bag in his lap. NAP places a pt’s drainage bag on a lowered side rail or on the floor |
| Which of the following are true regarding the impact of aging related to urinary elimination? (Select all that apply.) | Aging can affect continence if the patient experiences impaired mobility or decreased muscle tone. The elderly are at increased risk for urinary tract infection because of retained urine in the bladder. |
| During change-of-shift report the nurse states that a patient has early renal failure and to be alert to this when administering medications. Why would this be a concern? | The kidneys assist in the detoxification of medication metabolites. |
| The nursing instructor is reviewing the renal system and urinary catheterization with her students. Which statement, if made by a nursing student, indicates that further instruction is needed? | The nurse may use clean technique to insert an indwelling catheter." |
| A 53-year-old pt is being treated for hypertension and a history of thrombophlebitis (blood clots). She comes to the clinic complaining, "I have to get up all night to go to the bathroom, and I think my urine looks orange!" What is the best response? | What medications are you taking and when?" |
| A 68-year-old female is admitted for knee replacement surgery w/ expected hospital stay of 2 weeks. She has no known allergies. Provider has ordered an indwelling catheter to be inserted preoperatively. Which catheter should the nurse choose? | 14 French, 5-mL balloon, latex catheter |
| A health care provider has ordered an indwelling catheter to be inserted for bedside drainage. Which of the following is NOT an expected indication for catheterization with an indwelling catheter? | To determine urinary retention |
| A nurse is explaining the procedure for inserting an indwelling urinary catheter. Which of the following explanations regarding anchoring of the catheter would be most accurate? | It is important to anchor the catheter tubing to minimize the risk for urethral trauma and bladder spasms from traction and to prevent accidental dislodgment. |
| A nurse inserting an indwelling urinary catheter in a female patient advances the catheter and obtains clear yellow urine. What is the next action the nurse should take? | Advance catheter another 1 to 2 inches and inflate balloon. |
| The nurse has inserted a catheter 7.5 cm (3 inches) in a female patient and obtains no urine return even though her bladder is distended. What action should the nurse take at this time? | Leave the catheter in the vagina as a landmark and insert another sterile catheter. |
| The nurse has a sterile urinary catheter and sterile gloves. Choose the remaining equipment the nurse will need to insert a straight urethral catheter: (Select all that apply.) | Sterile cotton balls. Antiseptic solution. Water-soluble lubricant. Sterile forceps |
| Reasons for lack of urine after inserting a straight catheter include: (Select all that apply.) | The catheter is outside of the bladder. The catheter is inserted in the vagina rather than in the urethra of a female patient. |
| A nursing student is watching a nurse catheterize a female patient with an indwelling catheter. Which of the following, if it occurs, indicates a break in sterile technique? (Select all that apply.) | The nurse inserts the urinary catheter, and when urine does not return, removes the catheter and makes a second attempt to locate the urethra with the same catheter. SEE NEXT |
| The nurse lubricates the catheter and places it back into the sterile tray when it uncoils and touches the bed. After the nurse cleans the labia, the labia become slippery and closed as the nurse attempts to obtain a clear view of the urethra. | |
| Which of the following actions associated with urinary catheterization could cause a potential problem? | Keeping the foreskin retracted after catheterization. |
| A 40-year-old male pt has been admitted for abdominal surgery. He has no history of prostate problems. The health care provider has ordered that the patient be catheterized. Which of the following would be an appropriate-size catheter for this patient? | 16 French, 5-mL balloon |
| As part of catheter insertion assessment, where should the nurse palpate? | Above the symphysis pubis |
| Nurse is inserting an indwelling Foley catheter in a male pt. Nurse asks the pt to bear down as if to void & slowly inserts the catheter through the urethral meatus. Advance the catheter and meets resistance. What is the best initial action at this time? | Ask the patient to take slow deep breaths while inserting the catheter slowly. |
| The nurse is catheterizing a female patient and obtains a clear amber urine return. As the nurse begins to inflate the balloon, the patient complains of pain and resistance is felt. What is the nurse’s best action? | Allow fluid to flow back into syringe and advance the catheter a little more before attempting to reinflate. |
| The nurse is reviewing urinary catheter care with a newly hired nursing assistive personnel (NAP). Which statement made by the NAP indicates further instruction is needed? | The bedside drainage bag should only be emptied when it is full.” |
| The NAP documents “Peri-care given” next to “Urinary Catheter” on a patient with an indwelling urinary catheter. What is the best explanation of what the NAP did after application of clean gloves? The NAP: | stabilized the catheter and washed the catheter with soap and water from where the catheter enters the meatus down 4 inches toward the drainage tubing. |
| Which of the following indicates a reason for notifying the health care provider to get an order for removal of an indwelling catheter? | The patient’s urine appears cloudy with a foul odor. |
| Identify the indicators of a UTI: (Select all that apply.) | Fever. Complaints of pain w/ urination. Lower abdominal pain. Cloudiness of the urine. |
| Which of the following steps should you take before removing fluid from the balloon in an indwelling urinary catheter? (Select all that apply.) | Attach a 10 mL or larger syringe to the balloon port and allow the water to passively fill the syringe. Gently aspirate the syringe plunger if water remains in the balloon. |
| A pt had an indwelling catheter for 3 weeks. The patient had the catheter removed 3 hours ago and now complains of having to go to the bathroom frequently and that it is painful to void. Which instruction is appropriate for the nurse to give the patient? | This is a normal occurrence after having a catheter in place for more than several days." |
| If a patient's indwelling catheter is removed at 0900, the patient should be due to void by: | 1500 to 1700 (3:00 PM to 5:00 PM) |
| Which of the following is the best example of documentation on a patient with a urinary catheter? | Catheter care provided; no encrustation noted. Urinary catheter patent and draining clear yellow urine to bedside drainage bag. |
| The nurse is reviewing how to perform a bladder scan for determining postvoid residual (PVR) with nursing assistive personnel (NAP). Which of the following statements, if made by the NAP, indicates understanding? (Select all that apply.) | I will measure and record the patient’s intake and output. I will apply ultrasound gel above the patient’s symphysis pubis." I should point the scanner head downward toward the bladder |
| The nurse works on a surgical unit. For which of the following patients would a nurse expect to perform a bladder scan? (Select all that apply.) | patient who had an indwelling urinary catheter removed 8 hours ago and voided 30 mL once since it was removed. patient who complains she is having urinary incontinence and never had this problem before. A pt who is postoperative for urological surgery. |
| Four patients had a bladder scan for PVR. For which of the following patients would further investigation be required? | A patient with PVR measurements of 125 mL and 150 mL. |
| The nurse is to determine PVR on a patient who has been experiencing incontinence, but a bladder scanner is unavailable. What is the nurse’s best action? | Have the patient void and measure the volume, then perform straight catheterization. |
| The patient is to have intermittent irrigation of a double-lumen urinary catheter. The patient asks why the nurse is kinking the drainage tubing and putting a rubber band on it. What is the nurse’s best response? | This prevents the irrigating solution from going down into your drainage bag rather than into your bladder." |
| NAP reports the pt x 1 day postop bladder surgery complains of lower abd pain. Palpates the pt’s bladder, it’s distended, there has not been any change in amount of urine last 2 hrs in drainage bag. Vital signs w/in normal limits. What is best action? | Ensure there are no kinks in drainage tubing, and if none, notify health care provider for possible bladder irrigation order. |
| pt returned from urological surgery with closed continuous bladder irrigation. The patient’s vital signs are within normal limits. The patient’s wife voices concern regarding the “bloody-red” appearance of the drainage. What is the nurse’s best response? | This is normal at this time; the drainage will become lighter and appear blood tinged in 2 to 3 days." |
| The nurse is preparing continuous bladder irrigation. Which of the following actions by the nurse would be appropriate? (Select all that apply.) | Performing hand hygiene and donning clean gloves. Priming infusion tubing w/ irrigating solution. Calculating urinary output as amount of irrigant infused subtracted from the amount in the drainage bag. Monitoring & emptying the drainage bag as needed. |
| nurse is performing preop teaching for pt having urological surgery. nurse informs the pt he will likely require closed bladder irrigation following the surgery. The pt asks the purpose is for bladder irrigation. What would be a correct response? | Bladder irrigation may be used to instill medication into the bladder. Irrigating the bladder prevents any clots or sediment from blocking urinary drainage." |
| nurse is teaching the male patient and family caregiver about the advantages of a condom catheter. Which of the following should be included in the teaching? (Select all that apply.) | It is relatively safe and noninvasive. It is a convenient method of draining urine. It is used for male patients who are incontinent. It carries less risk of developing a UTI than an indwelling catheter. |
| Which of the following would be inappropriate to delegate to NAP? | Indwelling catheter insertion. |
| Which of the following could be considered negligence? | A regular condom catheter is removed every 3 days |
| During application of the condom catheter, the adhesive strip falls to the floor. What is the nurse’s best action? | Obtain another adhesive strip from condom catheter kit. |
| The nurse is assessing the patient’s condom catheter. Which of the following most likely indicates the condom catheter should be removed? | Redness and/or excoriation of the penis |
| The NAP is applying a condom catheter to the patient. The patient asks, “What is the purpose of the skin preparation solution?” The NAP correctly responds: | The skin preparation solution prevents skin irritation and should be dry before the condom catheter is applied.” |
Created by:
alishalynne93
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