urinary catheter dynamic quiz

A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain, and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions. A. Hemolvtic B. Febrile C. Circulatory overload D. Sepsis

A. Hemolytic rationale: A hemolytic reaction occurs when the client's blood is incompatible with the donor's blood. Chills, low back pain, hypotension, and tachycardia are indications of a hemolytic transfusion reaction.

A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to ease the passage of the catheter through the urinary meatus? A. "Bear down." B. "Perform Kegel exercises." C. "Hold your breath." D. "Raise your head off of the pillow."

A. "Bear down." rationale: The nurse should ask the client to "bear down" gently as if to void. This can enable the nurse to better visualize the urinary meatus and promote relaxation of the external urinary sphincter. Additionally, this will ease the passage of the catheter through the urinary meatus.

A nurse is caring for a postoperative client who has an indwelling urinary catheter for gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first? A. Check to determine if the catheter tubing is kinked B. Palpate the bladder C. obtain a prescription to irrigate the catheter with 0.9% sodium chloride D. Encourage the client to drink more fluids

A. Check to determine if the catheter tubing is kinked rationale: The nurse should apply the least invasive priority-setting framework when caring for this client, which assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety. This approach reduces the number of organisms introduced into the body, decreasing the number of facility-acquired infections. Hence, the first action the nurse should take is to inspect the tubing carefully, straighten any kinks, and ensure there are no dependent loops. A lack of drainage is often due to a kink in the tubing or the client lying on it.

A charge nurse is preparing assignments for the upcoming shift. Which of the following tasks should the charge nurse delegate to an assistive personnel (AP)? A. Perform a simple dressing change. B. Interpreting a client's blood glucose reading C. Providing advice when speaking to a client's family member on the phone D. Determining the effectiveness of a client's urinary catheter

A. Perform a simple dressing change. rationale: The nurse should identify that the completion of a simple dressing change is within the AP's range of function. Therefore, the charge nurse can delegate this task to an AP.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? A. Place the drainage bag on the client's abdomen when transferring from a bed to cart B. Empty the drainage bag when half-full of urine C. Rest the drainage bag on the floor when closing the drainage spigot during emptying D. Disconnect the drainage bag when obtaining a urine specimen

B. Empty the drainage bag when half-full of urine rationale: The nurse should empty the drainage bag when half-full of urine. A drainage bag that is too full can place tension on the catheter tubing, resulting in trauma to the urethra and urinary meatus.

A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing? A. Lateral thigh B. Lower abdomen C. Mid-abdominal region D. Medial thigh

B. Lower abdomen rationale: After inserting an indwelling urinary catheter, the nurse should secure the catheter tubing to the client's upper thigh or lower abdomen, by using adhesive tape or catheter securement device. This location will decrease tension and trauma to the urethra

A nurse is planning to delegate the postoperative care of a client following an appendectomy. Which of the following actions should the nurse assign to an assistive personnel (AP)? A. Showing the client how to use the patient-controlled analgesia pump. B. Recording urinary output after emptying the indwelling urinary catheter. C. Assisting the client out of bed and into a chair for the first time after surgery. D. Checking the client's abdominal wound dressing.

B. Recording urinary output after emptying the indwelling urinary catheter. rationale: Emptying an indwelling urinary catheter and recording intake and output are within the scope of practice for an AP. These tasks are routine and have predictable outcomes; therefore, the nurse may delegate this task to an AP.

A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique? A. Applying sterile gloves to open catheter package B. Wiping the labia minora in an anteroposterior direction C. Spreading the labia with the dominant hand D. Using a cotton ball to wipe the right and left labia majora

B. Wiping the labia minor in an anteroposterior direction rationale: The nurse should wipe anteroposteriorly both the right and left labia minor with separate cotton swabs to destroy any microorganisms in the area that would contaminate the catheter.

A charge nurse on a medical-surgical unit is making client assignments for the oncoming shift. Which of the following clients should the charge nurse assign to a licensed practical nurse (LP)? A. A client who requires an updated plan of care following a diagnosis of cancer B. A client who is postoperative following a total hip replacement and requires discharge teaching C.A client who has a prescription for irrigation of an indwelling urinary catheter D. A client who has just arrived from PACU and requires a head-to-toe assessment

C. A client who has a prescription for irrigation of an indwelling urinary catheter rationale: it is within the scope of practice of an LP to irrigate an indwelling urinary catheter when prescribed by a provider.

A nurse delegated the task of emptying an indwelling urinary catheter drainage bag to an assistive personnel (AP). The nurse later observes the AP emptying the bag without wearing gloves. Which of the following actions should the nurse take? A. Notify the charge nurse about the incident B. Insist that the AP attend an in-service training about standard precautions C. Talk with the AP about the technique used D. Observe the AP a second time and intervene if the technique remains the same

C. Talk with the AP about the technique used rationale: The nurse who delegates a task is responsible for providing the right supervision and evaluation. The nurse is responsible for providing feedback to the AP and should reinforce the correct procedure for this task with the AP, which includes wearing gloves.

An assistive personnel (AP) is helping a nurse care for a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching? A. The AP uses soap and water to clean the perineal area. B. The AP tapes the catheter to the client's inner thigh. C. The AP hangs the collection bag at the level of the bladder. D. The AP ensures there are no kinks in the drainage tubing.

C. The AP hangs the collection bag at the level of the bladder. rationale: The AP should place the drainage bag below the level of the bladder to ensure proper drainage by gravity.

A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse have the client perform just before inserting the catheter? A. Swallow water B. Prepare for a painful sensation C. Hold her breath D. Bear down gently

D. Bear down gently rationale: Bearing down helps the nurse visualize the urinary meatus and relaxes the external sphincter, which facilitates the insertion of the catheter.

During the insertion of a urinary catheter for a client, the tip of the catheter brushes against the nurse's arm. Which of the following actions should the nurse take? A. Wipe the catheter with povidone-iodine and continue the catheter insertion. B. Soak the catheter in chlorhexidine for 15 min and then reattempt insertion. C. Continue with the catheter insertion. D. Obtain a new catheter and reattempt insertion.

D. Obtain a new catheter and reattempt insertion. rationale: The insertion of a urinary catheter is a sterile procedure. The only way to ensure sterility of the catheter the nurse plans to insert is by obtaining a new sterile catheter and following surgical asepsis throughout the insertion procedure.

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take? A. Withdraw the specimen from the drainage bag B. Cleanse the collection port with soap and water C. Place the specimen in a clean specimen cup D. Clamp the tubing below the collection port

D. Clamp the tubing below the collection port rationale: The nurse should clamp the tubing below the collection port to allow fresh, uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup.