BSN 205 Catherters Elimination

5. Minimum average hourly urine output is ________ mL.

30mL

Question 1: When performing catheter care, how many inches of the catheter will you cleanse after it exits the urinary meatus? 1 inch (2.5 cm) 2 inches (5 cm) 3 inches (7.5 cm) 4 inches (10 cm)

4 inches (10 cm) This is the optimum distance to reduce the presence of secretions or drainage on the exterior catheter surface.

1. The bladder normally holds as much as ________ mL of urine.

600 mL

Question 1: You have finished providing instructions to the NAP on catheter care and removal of an indwelling catheter. Which of the following situations should the NAP report to you? (Select all that apply.) A patient's drainage bag is below the level of the bladder. A patient has 800 mL of clear amber urine in her drainage bag. A patient has been incontinent of stool and his scrotum appears red. A patient's catheter was removed at 1500.

A patient has 800 mL of clear amber urine in her drainage bag. A patient has been incontinent of stool and his scrotum appears red. A patient's catheter was removed at 1500.

Question 1: Which of the following require the use of an indwelling catheter? (Select all that apply.) To determine whether there is any residual urine in a patient's bladder A patient scheduled for surgical repair of bladder An incontinent patient with significant impaired skin integrity An incontinent male who is able to completely empty his bladder To obtain a sterile sample from a patient who is unable to adequately cleanse his perineal area

A patient scheduled for surgical repair of bladder An incontinent patient with significant impaired skin integrity

Question 1: The nurse is caring for a patient with continuous bladder irrigation after urological surgery. Which of the following would be appropriate actions for the nursing assistive personnel? Report patient complaints of lower abdominal pain to the nurse. Hang a new bag of solution for the continuous bladder irrigation. Notify the nurse of any increase in patient's urine output. Immediately report that urine output appears straw colored.

Report patient complaints of lower abdominal pain to the nurse. The NAP should report patient complaints of pain, discomfort, or leakage of fluid around the catheter.

Question 8: If uncircumcised, the foreskin of the penis must be retracted before beginning urethral catheterization preparation. True False

True Always retract the foreskin before beginning urethral catheterization preparation.

Question 4: This patient states that she is allergic to materials made from rubber. You select a silicone catheter for her. True False

True An allergy to rubber should cause you to suspect a latex allergy as well.

Question 3: An 11-month-old is admitted for surgical repair of a cleft palate. You may anticipate the patient having decreased urinary output immediately after surgery. True False

True Anesthetics drugs decrease urinary output. The body will reduce urinary output as a compensatory mechanism to increase circulatory fluid volume.

Question 5: Any sign of infection should be reported to the health care provider before removing a indwelling catheter. True False

True Any unexpected outcome should be reported before proceeding. The health care provider may order a specimen to be obtained before removal.

Question 2: Having the patient bear down as if voiding will allow for easier passage of the catheter through the urethral meatus. True False

True Asking the patient to bear down will help relax the external sphincter and aid catheter insertion.

Question 1: An 11-month-old lacks voluntary control of urination. True False

True Before 18 to 24 months, children are unable to control urination.

Question 3: This patient's abdominal discomfort could be due in part to bladder distention as well as her surgery. True False

True Bladder distention can cause considerable discomfort, especially after abdominal surgery.

Question 1: Catheter care is performed to remove bacteria that could ascend through the urethral canal and lead to an infection. True False

True Catheter care removes bacteria along the outer surface of the catheter.

Question 4: Diuretics inhibit reabsorption of water by the kidneys, resulting in an increased urine output. True False

True Diuretics prevent reabsorption of water and some electrolytes, which increases urination.

Question 1: The condom catheter should be removed daily to evaluate the penis and surrounding skin for redness and excoriation, unless an extended-wear device is used. True False

True Evaluation of skin integrity should be done daily. The catheter should be checked every 4 hours, and the patient should be assessed for discomfort.

Question 6: A 40-year-old patient is admitted for an intravenous pyelogram due to severe flank pain. After the tests, the patient's fluid intake increases. This patient may have an increased urine output. True False

True If fluids, electrolytes, and solutes are balanced, increased fluid intake leads to increased urine production.

Question 4: NAP can remove indwelling urinary catheters. True False

True If trained and permitted by agency policy, NAP can remove urinary catheters. Remember to review the process with them.

Performing Closed Urinary Catheter Irrigation Question 1: If clots are present in a patient's urinary output, the rate of infusion of irrigating solution or frequency of intermittent catheter irrigation should be increased. True False

True In the presence of clots, the catheter irrigation rate or frequency of intermittent bladder irrigation should be increased to maintain patency and prevent occlusion.

Question 3: At least 10 cm (4 inches) of an indwelling urinary catheter that exits the meatus should be wiped with a clean washcloth during routine care. True False

True Moving away from the body in a circular motion is the correct procedure for cleaning the catheter.

Question 1: Your assessment of the patient should include exploring any history of previous catheterizations. True False

True This information may indicate prior difficulty with voiding or prior difficulties with catheter insertion or maintenance.

Question 10: The correct position for catheterizing a male patient is supine with legs slightly abducted. True False

True This is the correct position for catheterizing a male patient.

Question 3: Once the catheter is inserted, you should release labial retraction and hold the catheter close to the urethra. True False

True This is the correct procedure to stabilize the catheter.

Question 2: NAP can perform catheter care. True False

True This procedure can be taught to the NAP if permitted by agency policy.

Question 2: Swelling, drainage, and irritation of the urethral meatus may indicate localized infection. True False

True This should be reported and treated.

Question 5: Your assessment of a patient after removal of an indwelling urinary catheter should include urinary frequency. True False

True This will assist you in determining whether urinary function has returned to normal.

Question 7: When preparing for catheter insertion in a male, cleanse from the urethral meatus outward in a spiral motion, using a new cotton ball with each cleansing. True False

True Wipe in a circular motion starting at the meatus and moving outward; use each cotton ball only once.

Question 1: When cleansing the perineum, allow for only one pass with each cotton ball during preparation. True False

True Wipe in only one direction and use each cotton ball only once.

Question 1: When applying a condom catheter to a patient, you should leave 2.5 to 5 cm of space between the tip of the glans penis and the end of the condom catheter. True False

True You should allow space to prevent irritation of the glans penis and allow free passage of urine into the collecting tube and drainage bag.

Question 1: The nurse has delegated performing a bladder scan to nursing assistive personnel. The nurse sees the NAP pick up the bladder scanner and an alcohol pad. What else will the NAP need to perform this skill? A straight catheter, cleansing swabs and lubricant. Ultrasound gel. A basin of warm water. Nothing; the NAP has the necessary equipment. Nothing; the nurse should not delegate this skill to NAP.

Ultrasound gel Ultrasound transmission gel is also required and a paper towel or washcloth to wipe off the gel once the scan is complete.

1. A condom catheter is recommended for incontinent male patients who have complete and spontaneous bladder ________.

emptying

4. The ________ is the functional unit of the kidney that forms the urine.

nephron

2. Because the condom catheter is ________, there is a decreased risk for UTI.

noninvasive

2. Following catheter care, the urethral meatus should be free of ________ and encrustation.

secreations

Question 2: Which of the following unexpected outcomes, if experienced by the patient, should be reported to her health care provider? (Select all that apply.) Lack of urine after 1 hour More than 2500 mL of urine produced consistently every 24 hours (polyuria) Urine leakage around the catheter Inability to advance the catheter into the bladder The patient consistently produces less than 30 mL of urine per hour. Patient continues to complain of discomfort after insertion.

-Lack of urine after 1 hour -More than 2500 mL of urine produced consistently every 24 hours (polyuria) -Inability to advance the catheter into the bladder -The patient consistently produces less than 30 mL of urine per hour. -Patient continues to complain of discomfort after insertion.

Question 1: You return to the patient's room 1 hour after inserting an indwelling urinary catheter to evaluate the outcome of the procedure. What actions would you take? (Select all that apply.) Palpate above the patient's symphysis pubis. Empty the bedside drainage bag of 100 mL of urine. Ask the patient whether he is having any discomfort. Observe that the patient has approximately 100 mL of clear, straw-colored urine in the drainage bag. Determine that the drainage system is intact without urine leaking around the catheter. Offer the patient a glass of orange juice.

-Palpate above the patient's symphysis pubis. -Ask the patient whether he is having any discomfort. -Observe that the patient has approximately 100 mL of clear, straw-colored urine in the drainage bag. -Determine that the drainage system is intact without urine leaking around the catheter.

Question 1: Choose the size catheters that would be appropriate for the patient. (Select all that apply.) 10 French 12 French 14 French 16 French 20 French

14 French 16 French

4. After the catheter is removed, the patient should be able to void without discomfort and void a minimum of ________ mL of urine with each voiding.

150 mL

2. The urge to urinate can be sensed when the bladder contains ________ mL in an adult.

150-200 mL

Question 1: Before inserting a straight catheter, you review with the patient why you are doing so. Which of the following explanations from the patient would indicate that he understood why a straight catheter insertion was necessary? (Select all that apply.) "I am uncomfortable because I am unable to empty my full bladder. Insertion of a catheter will relieve my discomfort and empty my bladder." "I have just voided and the doctor wants to determine whether I am completely emptying my bladder." "I may have a bladder infection. A sterile urine sample is needed and I am unable to collect it myself." "I am going to have surgery and a catheter will prevent me from having trouble passing urine after surgery." "During the day when I am awake, I completely empty my bladder. When I am asleep at night, I lose bladder control."

"I am uncomfortable because I am unable to empty my full bladder. Insertion of a catheter will relieve my discomfort and empty my bladder." "I have just voided and the doctor wants to determine whether I am completely emptying my bladder." "I may have a bladder infection. A sterile urine sample is needed and I am unable to collect it myself."

A patient has a condom catheter due to urinary incontinence. His wife calls the nurse and reports that the patient's scrotum and penis appear "red and raw." She asks you if she should put some cornstarch on the area. Question 1: Which of these responses would be appropriate for the nurse to give the patient's wife? "Yes, you can put some cornstarch on the area and then reapply a new condom catheter; just make sure the adhesive isn't so tight." "It sounds like the tubing must have been kinked. Wash and dry his penis and apply some skin protectant before applying a new catheter." "Wash and dry the area well and apply the next-larger-size catheter. You may have to change the catheter more frequently." "I will notify the health care provider. Remove the catheter and avoid applying cornstarch or reapplying the catheter until the area is free from irritation."

"I will notify the health care provider. Remove the catheter and avoid applying cornstarch or reapplying the catheter until the area is free from irritation." Feedback Redness and excoriation around the penis result from pressure of adhesive or contact with urine. They may also suggest a possible latex allergy. The condom catheter should be removed and the health care provider notified. The catheter should not be reapplied until the penis and surrounding tissue are free from irritation.

Question 1: A nursing instructor is reviewing how to perform closed urinary catheter irrigation with a group of nursing students. Which of the following are accurate statements indicating learning has occurred? (Select all that apply.) "If the urine appears bright red or has clots, the irrigation rate should be increased until the drainage appears pink." "Sterile technique is required to perform continuous bladder irrigation but not intermittent bladder irrigation." "I should check on the patient frequently and empty the catheter drainage bag as needed." "Priming the tubing with irrigation solution before connecting it to the patient will help prevent bladder spasms." "For intermittent bladder irrigation, inject the irrigant rapidly to flush the tubing and dislodge any clots."

"If the urine appears bright red or has clots, the irrigation rate should be increased until the drainage appears pink." "I should check on the patient frequently and empty the catheter drainage bag as needed." "Priming the tubing with irrigation solution before connecting it to the patient will help prevent bladder spasms."

Question 1: An elderly terminally ill patient requires indwelling catheterization due to skin breakdown from urinary incontinence. She is weak and unable to maintain a position in bed without the aid of pillows. You and the NAP are in the room to perform the procedure. What tasks can you delegate to the NAP? (Select all that apply.) Assisting the patient into position for catheterization Holding the flashlight for catheter insertion Preparing the sterile field Inserting the indwelling catheter Holding the patient's hand

Assisting the patient into position for catheterization Holding the flashlight for catheter insertion Holding the patient's hand

Question 1: You are instructing nursing assistive personnel how to prevent infection in catheterized patients. Which of the following should you include in the teaching? (Select all that apply.) How to irrigate the catheter daily with sterile normal saline Avoiding kinks in the tubing or cautioning the patient not to lie on the tubing Removing any microorganisms that may have built up by disconnecting the tubing daily from the catheter and wiping with an alcohol pad Keep the urinary drainage bag below the level of the bladder. Make sure each patient has their own measuring receptacle for urine output.

Avoiding kinks in the tubing or cautioning the patient not to lie on the tubing Keep the urinary drainage bag below the level of the bladder. Make sure each patient has their own measuring receptacle for urine output.

Question 1: You have a basin with warm water, soap, washcloth, towel, and bath blanket. Choose the remaining items you will need to perform catheter care: (Select all that apply.) A urinary catheter kit Scissors and/or a safety razor Clean gloves An absorbent bed pad A urine collection bag

Clean gloves An absorbent bed pad

Question 2: You are changing a condom catheter on a male patient. You notice that pubic hair was caught in the elastic adhesive strip. What action should you take when applying a new condom catheter? Apply skin preparation to the pubic hair. Clip the hair at the base of the penis. Avoid the use of the elastic adhesive strip. Overlap the tape rather than use the spiral wrap

Clip the hair at the base of the penis. The hair may be clipped to prevent it from adhering to the condom or getting caught in the condom during application. Do not shave hair because this increases the risk for skin irritation. A hair guard may also be used as an alternative.

Question 1: You are reviewing abnormal findings related to urination with NAP/family members. Which of the following urine characteristics should be reported? (Select all that apply.) Cloudy Amber Red Ammonia smell Dark amber Less than 30 mL per hour of urine output

Cloudy Red Dark amber Less than 30 mL per hour of urine output

Question 3: A postvoid residual volume less than 100 mL is considered normal. True False

False A postvoid residual volume less than 50 mL is considered normal

Question 4: Removal of at least half of the fluid in the catheter balloon will ensure easy removal of the indwelling urinary catheter. True False

False All fluid must be removed before the catheter can safely be removed.

Question 1: An empty bladder is easily palpated. True False

False An empty bladder cannot be palpated as it is located below the symphysis pubis. A distended bladder is palpable. A full bladder with inability to void may indicate need to insert a catheter.

Question 1: When providing indwelling catheter care, you should clean around the anchor tapes to prevent the catheter from slipping out of the urethra. True False

False Anchor tapes must be changed daily and the skin inspected carefully. The balloon in the bladder prevents the catheter from falling out.

Question 3: Reduced fluid intake decreases bacterial growth in the urinary system. True False

False Decreased fluid intake can lead to an increase in bacteria and possible infection.

Question 11: The foreskin must remain retracted after catheterization. True False

False Failure to reduce the foreskin after catheterization can result in paraphimosis (constriction of the foreskin).

Question 2: Infants and young children are better able to concentrate urine than the adult. True False

False Infants and young children are unable to concentrate urine and reabsorb water effectively.

Question 2: Two hours have elapsed since the condom catheter was applied. You should verify that the sheath is intact without leakage and that the patient is comfortable. True False

False Initial assessment should occur within 30 minutes of application.

Question 5: It is normal for older adults to experience increased urinary frequency, retention of urine in the bladder, and incontinence. True False

False It is never normal for an older adult to be incontinent.

Question 2: Closed catheter irrigation may be performed with a single- or double-lumen urinary catheter. True False

False Open catheter irrigation may be performed with single- or double-lumen urinary catheters. A triple-lumen catheter is necessary to performed continuous closed catheter irrigation.

Question 6: Within 6 to 8 hours of urinary catheter removal, patients should be able to void, without difficulty, at least 75 to 100 mL of urine. True False

False Patients should be able to void at least 150 mL within 6 to 8 hours of catheter removal.

Question 12: Resistance during catheter insertion with a male is always a sign of urethral obstruction. True False

False Resistance is felt before the internal sphincter relaxes. Maintain firm pressure against the sphincter for a few seconds and then continue to advance the catheter.

Question 4: The catheter should be inserted at least 17 cm into the urethra of the female patient. True False

False The catheter should only be inserted 5 to 7.5 cm (2 to 3 inches) for the female patient.

Question 6: The fenestrated drape is placed under the patient's buttocks before the procedure. True False

False The fenestrated drape is used to cover the genital and perineal region.

Question 3: The output in the urinary catheter drainage bag should not exceed the amount of irrigant infused during closed catheter irrigation True False

False The output should be more than the volume of irrigant infused. If the output is less, this may indicate catheter obstruction.

Question 2: You expect that she will have a low urinary output (less than 30 mL per hour) because she has only been eating small meals since her surgery. True False

False This patient has an intravenous infusion. Her urine output should be at least 30 mL per hour.

Question 2: To obtain an accurate reading for postvoid residual, the bladder scan should be performed 15 to 30 minutes after the patient voids. True False

False To obtain an accurate reading for postvoid residual, the bladder scan should be performed 5 to 15 minutes after the patient voids.

Question 1: The nurse is caring for a patient receiving closed continuous bladder irrigation. The nurse knows to monitor the patient for clots in the tubing. Which of the following problems could be caused by clots in the drainage tubing? (Select all that apply.) Bright-red bleeding occurs with the irrigation infusion wide open. Irrigation solution does not flow at prescribed rate. Patient complains of pain with irrigation. Drainage output is more than amount of irrigation solution infused. Drainage output is less than amount of irrigation solution infused.

Irrigation solution does not flow at prescribed rate. Patient complains of pain with irrigation. Drainage output is less than amount of irrigation solution infused.

Question 1: Which of the following situations indicates catheter care should be performed? (Select all that apply.) It has been 8 hours and the patient has not received catheter care. A patient complains of bladder fullness and there is minimal urine output. An elderly patient is incontinent of stool. While assessing the urinary drainage system, you notice buildup of secretions on the urinary catheter near the meatus. The bedside drainage bag touched the floor.

It has been 8 hours and the patient has not received catheter care. An elderly patient is incontinent of stool. While assessing the urinary drainage system, you notice buildup of secretions on the urinary catheter near the meatus.

A patient with an established indwelling urinary catheter has been running a fever and complaining of flank pain. Urine in the patient's drainage bag appears cloudy with sediment and has a foul odor. The nurse assesses the patient's urethral meatus and surrounding skin. There is absence of redness or discharge. Question 1: What is your best action at this time? Remove the catheter. Notify the health care provider. Continue to monitor the patient. Document the assessment.

Notify the health care provider. These are symptoms of a urinary tract infection. You should notify the health care provider.

Question 1: The patient's indwelling catheter was removed without difficulty at 0800. It is now 1300 and the patient has not yet voided since removal of the catheter. What should you do? (Select all that apply.) Palpate for bladder fullness and inquire about discomfort. Ensure that the patient is drinking adequate fluids. Notify the health care provider. Reinsert the catheter. Provide privacy.

Palpate for bladder fullness and inquire about discomfort. Ensure that the patient is drinking adequate fluids. Provide privacy.

Question 1: The nurse is caring for a patient on the first postoperative day after urological surgery. The patient has continuous bladder irrigation. Which of the following would be cause for concern? Urine output is red. Urine output is greater than volume of irrigating solution instilled. Patient complaints of bladder spasms. Patient is afebrile, with no foul odor of urine.

Patient complaints of bladder spasms. Bladder pain or spasms may indicate the bladder is not emptying as expected.

Question 1: The nurse is preparing to perform a bladder scan and determine postvoid residual of a patient. What assessment information would be significant to include? (Select all that apply.) Patient's last 24-hour intake was 1800 mL. Unable to palpate bladder. Patient's last voiding was 10 minutes ago. Patient consumed 100% of previous meal. Patient is able to transfer to bedside commode. Patient's last 24-hour output was 1550 mL.

Patient's last 24-hour intake was 1800 mL. Unable to palpate bladder. Patient's last voiding was 10 minutes ago. Patient is able to transfer to bedside commode. Patient's last 24-hour output was 1550 mL.

Question 1: A bladder scanner measures the amount of urine in the bladder, especially at lower volumes. True False

Question 1: A bladder scanner measures the amount of urine in the bladder, especially at lower volumes. True A bladder scanner creates an ultrasound image of the bladder for measuring the volume of urine in the bladder, especially lower volumes.

Question 1: A nurse is reviewing with the nursing students the differences between a straight and indwelling urinary catheter. Which of the following statements are correct descriptions related to an indwelling catheter? (Select all that apply.) Requires a health care provider's order for insertion Requires sterile technique for insertion Used for one-time bladder emptying May remain in place for an extended period A balloon is unnecessary to hold the catheter in place. Has a closed drainage system

Requires a health care provider's order for insertion Requires sterile technique for insertion May remain in place for an extended period Has a closed drainage system

3. ________ technique is used to insert a urinary catheter.

Sterile

Question 1: The nursing assistive personnel (NAP) is preparing to apply a condom catheter to a male patient. The nurse observes the NAP gathering supplies. Which of the following types of tape securement device should the NAP use to apply the condom catheter? Plastic waterproof tape (IV tape) Strap from condom catheter kit Soft, cloth tape Nonallergenic paper tape

Strap from condom catheter kit The NAP should use the stretchable strap or internal adhesive that comes in the condom catheter kit. Other types of tape could cause constriction of blood flow to the penis.

Question 2: You receive an order to obtain a urine specimen for culture and then discontinue the indwelling catheter. Which of the following is correct regarding delegation? The NAP can obtain the urine specimen and remove the catheter. You should obtain the urine specimen and the NAP can remove the catheter. The NAP can obtain the urine specimen and you should remove the catheter. You should never delegate either task.

The NAP can obtain the urine specimen and remove the catheter. Obtaining a urine specimen from an indwelling catheter and removal of a catheter may be delegated to NAP who are familiar with aseptic technique.

Question 1: The nurse notices in the health history the patient has previously had a hysterectomy. Why would this information be significant when performing a bladder scan? The gender designation on the bladder scanner should be set to male. Women who have had a hysterectomy are more likely to have false readings. You do not have to press the scanner head as deeply to obtain a reading. A PVR of 100 mL would be considered normal for a woman who had a hysterectomy.

The gender designation on the bladder scanner should be set to male. Following manufacturer guidelines, the gender designation on the bladder scanner should be set to male if the patient had a hysterectomy.

Question 1: A patient had 2300 mL of irrigating solution instilled in the past 24 hours for continuous bladder irrigation. The amount of drainage measured was 3850 mL. What would be an accurate evaluation of this data? The health care provider should be notified of the lack of urinary output. The patient had 1550 mL urine output in the past 24 hours. The urinary catheter must be occluded with a clot. The patient had approximately 160 mL/hour urine output.

The patient had 1550 mL urine output in the past 24 hours. Measure actual urine output by subtracting total amount of irrigation fluid infused from total volume drained into basin. The urine output was 3850 − 2300 = 1550 for 24 hours.

Question 1: You are caring for an elderly patient with a history of dementia and a neurogenic bladder. You have determined that the patient would benefit from application of a condom catheter. Which of the following are expected outcomes of this type of catheter application? (Select all that apply.) The patient's skin is dry and catheter is secure. The patient's bladder distention is relieved. The patient's penile shaft is free of skin irritation. The patient is cooperative and his family can explain the purpose of the procedure.

The patient's skin is dry and catheter is secure. The patient's penile shaft is free of skin irritation. The patient is cooperative and his family can explain the purpose of the procedure.

Question 1: A patient is to have a postvoid residual urine measurement. Which of the following would require correction? -The nurse delegates the performance of a bladder scan to NAP. -The bladder scan is performed after the patient has voided. -The timing of the bladder scan is 30 minutes postvoid. -The nurse assesses the patient's abdomen for distention.

The timing of the bladder scan is 30 minutes postvoid. To obtain the most reliable reading, the PVR should be measured within 5 to 15 minutes of voiding.

Question 6: Ensuring that the patient receives adequate fluids will improve the probability that the patient will void within 6 to 8 hours after catheter removal. True False

True Adequate fluid intake will assist the patient in voiding.

Question 9: The catheter should be inserted to the bifurcation of the drainage and balloon inflation port in the male patient. True False

True Advancement of catheter to the bifurcation of the drainage and balloon inflation port ensures proper placement of catheter through the longer urethra for male patient.

Question 5: The patient should receive an explanation of the procedure regardless of their consciousness status. True False

True Always explain the procedure before you begin.

3. The skin under the tape site should be intact. Open, ________, or reddened skin indicates a problem.

abraded

1. When evaluating catheter care, you should inspect the urethral meatus and the surrounding tissue to determine if the area is ________ and/or if the patient has any irritation.

cleansed properly