Bowel/Urinary pt 2
The nurse has completed an intermittent straight urinary catheterization of a female patient. Which action would the nurse delegate to nursing assistive personnel (NAP)? A. Measure and empty the urine. B. Palpate the abdomen. C. Ask the patient if she has any pain. D. Document the procedure.
A. Measure and empty the urine. Rationale: The NAP can measure and empty the urine collection tray after an intermittent straight catheterization. The nurse cannot delegate physical assessment, pain assessment or documenting the procedure to NAP.
Which statement best illustrates the nurse's understanding of the role of nursing assistive personnel (NAP) when inserting an indwelling urinary catheter in a female patient? A. "Please direct the light to better illuminate the patient's perineal area." B. "You need to be comfortable inserting a catheter in a patient of her size." C. "See if a size 14-French catheter is big enough." D. "Find out if the patient has any allergies to latex or iodine."
A. "Please direct the light to better illuminate the patient's perineal area." Rationale: This is the correct answer. No aspect of the skill of indwelling urinary catheter insertion may be delegated to NAP, but the nurse may delegate related tasks, such as redirecting the lighting during the procedure. Neither indwelling urinary catheter insertion, catheter selection, assessment of the patient for allergies, nor any other aspect of the skill may be delegated to NAP, although related tasks may be delegated.
Which action(s) would minimize the patient's risk for injury during insertion of an indwelling urinary catheter? A. Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based substances B. Thoroughly cleansing the patient's perineal area with povidone-iodine solution before inserting the catheter C. Performing proper hand hygiene and applying gloves before inserting the catheter D. Terminating the insertion if the patient reports pain at any time during the procedure
A. Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based substances Rationale: This is the correct answer. Serious allergic reactions may occur if the patient has an allergy to latex, antiseptic, tape, or iodine-based cleanser. Thoroughly cleansing the patient's perineal area reduces the risk for infection during catheter insertion but does not reduce the patient's risk for injury. When inserting a catheter, gloving should be sterile. Proper hand hygiene and sterile gloving reduce the risk for infection during catheter insertion but do not reduce the patient's risk for injury. Insertion of a urinary catheter is uncomfortable, but it is not always necessary to terminate the procedure if the patient reports a tolerable level of pain during the process.
While attempting to perform a straight catheterization for a male patient, the nurse advances the catheter 3 to 4 inches into the meatus but observes no urine flow. Which action would the nurse take at this time? A. Continue to advance the catheter until 5 to 7 inches of the catheter tube has been introduced into the urethra. B. Withdraw the catheter to 1 inch, and ask the patient to cough. C. Encourage the patient to cough as the catheter is advanced. D. Apply pressure to the patient's lower abdomen over the bladder.
A. Continue to advance the catheter until 5 to 7 inches of the catheter tube has been introduced into the urethra. Rationale: This is the correct option, because the urethra may be longer than 3 to 4 inches. Withdrawing the catheter will not help drain urine from the bladder. Having the patient bear down will not help facilitate the flow of urine. Applying pressure to the lower abdomen over the bladder will not help the catheter reach the bladder.
During intermittent open bladder irrigation, a patient complains of pain. Which action would the nurse take first? A. Examine the drainage tubing for clots, sediment, and kinks. B. Notify the health care provider. C. Leave the irrigation drip wide open. D. Monitor the patient's vital signs.
A. Examine the drainage tubing for clots, sediment, and kinks. Rationale: This is the correct answer. If the patient complained of pain during intermittent open bladder irrigation, the nurse would first examine the drainage tubing for clots, sediment, and kinks. The nurse can notify the health care provider later if he or she is unable to troubleshoot the cause of the pain. This patient is receiving intermittent irrigation. An irrigation drip is not used for this procedure. Monitoring the patient's vital signs would be appropriate if the patient were demonstrating other signs of a urinary tract infection (UTI). Assessing for UTI, however, is not the nurse's first priority in this situation.
Which measure may be taken to minimize the staff's risk for infection from a urine specimen? A. Firmly securing the lid of the urine specimen container B. Using a sterile urine specimen container C. Using a sterile syringe to access the sampling port D. Placing the urine specimen container in the refrigerator until the laboratory comes to get it
A. Firmly securing the lid of the urine specimen container Rationale: Securing the specimen container lid is one way to minimize the risk for infection to the staff. Using a sterile container, a sterile syringe or refrigeration of the specimen will not minimize the risk for infection to the staff.
Which action would the nurse take to manage continuous urinary catheter irrigation for a patient whose urine is bright red and contains clots? A. Increase the irrigation drip rate. B. Notify the patient's health care provider of the blood and clots in the urine. C. Encourage the patient to increase fluid intake. D. Apply ice to the patient's lower abdominal area.
A. Increase the irrigation drip rate. Rationale: This is the correct answer. The nurse would increase the irrigation drip rate to flush the urinary tract until the urine was only tinged pink with blood. It is not necessary to notify the patient's health care provider at this time. Encouraging the patient to increase fluid intake is appropriate but will not help with the immediate problem. Applying ice to the lower abdominal area is a not an effective intervention in this situation.
Which action would best minimize a patient's risk for infection during removal of an indwelling urinary catheter? A. The nurse or nursing assistive personnel (NAP) removing the catheter must employ clean technique. B. A registered nurse, not NAP, must remove the catheter. C. Catheter removal must be executed within 10 minutes of beginning the procedure. D. Catheter removal must take place within 5 days of catheter insertion.
A. The nurse or nursing assistive personnel (NAP) removing the catheter must employ clean technique. Rationale: Using clean technique is the best way to minimize the risk of introducing pathogens to the patient's urinary tract. Trained NAP may remove an indwelling urinary catheter if allowed by agency policy. Although the procedure should be accomplished in a timely manner, doing so will not minimize the risk of infection. Although it is best to limit the use of an indwelling urinary catheter to the shortest time possible, doing so will not affect the risk of infection during the actual removal process.
Which statement might the nurse make to nursing assistive personnel (NAP) caring for a patient who has just had an indwelling urinary catheter removed? A. "Teach the patient the signs of a urinary tract infection." B. "Tell me when and how much the patient first voids." C. "Explain that voiding might be uncomfortable for 4 to 5 days." D. "Assess the patient for a distended bladder before the end of the shift."
B. "Tell me when and how much the patient first voids." Rationale: The nurse may delegate to NAP the task of reporting the time and amount of the patient's first voiding after removal of an indwelling urinary catheter. Patient education and patient assessment cannot be delegated to NAP. Initial postremoval void might be slightly uncomfortable but after that, no discomfort should be present.
A patient is told the home care nurse will be measuring and recording intake and output (I&O) at home. What will the home care nurse do first? A. Supply a urine hat. B. Explain to the patient why I&O has been ordered. C. Assess the patient's ability to self-monitor and record I&O. D. Provide the patient's family with instructions.
B. Explain to the patient why I&O has been ordered. Rationale: This intervention is most appropriate because it will help the patient understand why I&O is to be measured at home and will improve compliance with the task. Supplying the patient with a urine hat does not explain why the patient needs to measure I&O at home. Assessing the patient's ability to monitor his or her own I&O does not explain why the patient needs to measure I&O at home. Although providing instructions to the patient's family is important, this option does not explain why the patient needs to measure I&O at home.
Which is not an expected outcome on a first voiding after catheter removal? A. Mild burning B. Fever and back pain C. Producing only a small amount of urine D. Discomfort
B. Fever and back pain Rationale: The nurse would instruct the patient to report signs of a UTI, such as fever and back pain. These signs are unlikely to be present during the patient's first voiding after catheter removal. Many patients experience mild burning, produce only a small volume of urine, and experience discomfort with their first voiding after catheter removal.
Which action will ensure that a sterile urine specimen is handled properly in order to help obtain reliable results? A. Placing the specimen in a biohazard bag B. Having someone take the specimen to the lab immediately C. Cleaning the outside surface of the container D. Ensuring that a stock of sterile urine collection kits is available
B. Having someone take the specimen to the lab immediately Rationale: Having someone take the specimen to the lab immediately will help to ensure reliable results. The specimen must be delivered to the lab within 20 minutes of collection. Placing the specimen in a biohazard bag would protect others from possible contamination from the urine specimen, but it will not ensure reliable test results. Cleaning the outside surface of the container should not be necessary when collecting a sterile urine specimen through an indwelling urinary catheter. Ensuring that a stock of sterile urine collection kits is available would have no effect on the current sterile urine specimen.
While performing an intermittent straight urinary catheterization of a female patient, the nurse inadvertently inserts the catheter into the patient's vagina. Which action would the nurse take next? A. Remove the catheter, and rinse it thoroughly in sterile water for reuse. B. Keep the catheter in place, and begin again with a new sterile catheter. C. Remove the catheter, relubricate it, and insert it into the urinary meatus. D. Stop advancing the catheter, and notify the health care provider.
B. Keep the catheter in place, and begin again with a new sterile catheter. Rationale: This action is correct. If a straight catheter is inadvertently inserted into the vagina, it should be left in place as a landmark, and the nurse must begin the catheterization process again with a new sterile catheter. If a straight catheter is inadvertently inserted into the vagina, it should be left in place as a landmark, and the nurse must begin the catheterization process again with a new sterile catheter. Reusing the catheter, even after rinsing it in sterile water, is inconsistent with sterile technique. Inserting the catheter into the patient's urinary meatus after it was in the vagina is inconsistent with sterile technique. It is unnecessary to notify the health care provider because no urethral obstruction has been encountered.
Which observation indicates that instruction given to nursing assistive personnel (NAP) in caring for a patient with an indwelling urinary catheter has been effective? A. The collection bag has been placed on the side rail of the bed. B. The excess catheter tubing has been coiled beside the patient's inner thigh. C. The collection bag has been placed on the bed. D. The collection bag is held above the level of the bladder while ambulating the patient.
B. The excess catheter tubing has been coiled beside the patient's inner thigh. Rationale: The excess drainage tubing should be coiled next to the patient's inner thigh, to facilitate urine flow. The urine drainage bag should not be placed on a side rail, because the rail is above the level of the patient's bladder. The collection bag should not be placed on the bed next to the patient, because this level is above the patient's bladder. NAP must hold the collection bag below, not above, the level of the patient's bladder so that urine can drain easily into the bag.
While performing catheter care, the nurse moves her hand, allowing the patient's labia to close around the catheter. Why would the nurse repeat this part of the care? A. The catheter may have traumatized the labia. B. The labia have contaminated the area. C. The patient's perineal area must be reassessed for infection. D. The nurse must ensure that the catheter is not pulling on the bladder.
B. The labia have contaminated the area. Rationale: The nurse will repeat the perineal care because the labia closed around the catheter and contaminated the perineal area. The catheter will not traumatize the labia. The nurse will assess the patient's perineal area for signs of infection and then repeat the perineal care to ensure cleanliness, not to re-assess for infection. The nurse must ensure that the catheter is not pulling on the bladder; however, the cleansing must be repeated because the labia closed around the catheter and contaminated the area.
When preparing to discharge a patient who had an indwelling urinary catheter removed 24 hours ago, the nurse would offer patient education regarding which common complication? A. Urinary incontinence B. Urinary tract infection (UTI) C. Adequate oral hydration D. Kidney stones
B. Urinary tract infection (UTI) Rationale: UTI may develop 2 to 3 days after indwelling urinary catheter removal, and the nurse would educate the patient to be alert for signs and symptoms of such an infection. Urinary incontinence is not a common complication of indwelling urinary catheter removal. Adequate hydration is not a complication of indwelling urinary catheter removal, but an intervention. The presence of kidney stones is not a common complication of indwelling urinary catheter removal.
Which action would the nurse take to minimize a patient's risk for injury during urinary catheter irrigation? A. Change the tubing every 8 hours. B. Use slow, even pressure when injecting the irrigating fluid. C. Adhere to aseptic technique during the irrigation process. D. Monitor the patient's temperature every 4 hours.
B. Use slow, even pressure when injecting the irrigating fluid. Rationale: This is the correct answer. Using slow, even pressure during the instillation of fluid into the bladder helps avert bladder trauma. Tubing does not need to be changed every 8 hours during an irrigation. Using aseptic technique reduces the risk for infection, not the risk for injury. Monitoring the patient's temperature helps assess for infection but does not reduce the risk for injury.
Which action would the nurse take to reduce the risk for a catheter-associated urinary tract infection (CAUTI) in a patient with an indwelling urinary catheter? A. Wear clean gloves when inserting the catheter. B. Inflate the balloon on the catheter before using it. C. Use the smallest-size catheter possible. D. Empty the urine by disconnecting the catheter from the collection bag.
C Use the smallest-size catheter possible. Rationale: This is the correct answer. To reduce the risk of CAUTI in a patient with an indwelling urinary catheter, the nurse would use the smallest-size catheter possible. To reduce the risk of CAUTI, the nurse would wear sterile, not simply clean, gloves to insert the indwelling urinary catheter. Inflating the balloon before inserting an indwelling urinary catheter would not reduce the risk of CAUTI. To reduce the risk of CAUTI in a patient with an indwelling urinary catheter, the urine collection device must remain a closed system. To keep the system completely closed, the urine must be removed from the device connected to the bag and not by disconnecting the catheter from the drainage bag.
Which statement reflects the nurse's understanding of the importance of accurate urinary output measurement for a patient with acute renal failure? A. "If the output begins to decrease, I will notify the physician immediately." B. "Increasing his fluid intake both orally and intravenously should boost his urine output." C. "I will use a collection system with an hourly measurement device added." D. "I will explain to the patient and family why I&O is being measured and recorded."
C. "I will use a collection system with an hourly measurement device added." Rationale: A collection system with an hourly measurement device added will improve the accuracy of measuring the urine. The decrease in output pertains to the evaluation of the data and does not pertain directly to accurate measurement of urine output. Increasing the patient's fluid intake both orally and intravenously does not pertain directly to accurate measurement of urine output, but rather to interventions for managing decreased urine output. Explaining to the patient and family why I&O is being measured and recorded does not pertain directly to accurate measurement of urine output, but rather to patient and family teaching.
Which instruction might the nurse give to nursing assistive personnel (NAP) helping to care for a patient receiving bladder irrigation? A. "Tell me how he tolerates the irrigation." B. "Be sure to check for signs of a urinary tract infection." C. "Measure and report the patient's temperature to me every 4 hours." D. "Ask the patient about pain level."
C. "Measure and report the patient's temperature to me every 4 hours." Rationale: This is the correct answer. Measuring and reporting temperature is a skill that may be delegated to NAP. The nurse would perform the bladder irrigation and monitor the patient's response; it would not be delegated to NAP. The nurse would assess the patient for signs and symptoms of UTI and pain assessment; these would not be delegated to NAP.
. When collecting a urine specimen from an indwelling urinary catheter, which action is most likely to ensure that sufficient urine is collected? A. Checking the patency of the indwelling catheter tubing B. Placing the urinary collection bag below the level of the bladder C. Clamping the catheter tubing for 15 minutes before collection D. Asking the patient to drink a glass of water 30 minutes before the collection
C. Clamping the catheter tubing for 15 minutes before collection Rationale: Clamping the catheter tubing for 15 minutes before collection will ensure that sufficient urine is available for the specimen. Checking the tubing will not ensure that enough urine is available for the specimen. The level of the collection bag has no bearing on ensuring that an adequate specimen can be collected, since a urine specimen cannot be taken from the collection bag. Asking the patient to drink a glass of water 30 minutes before the collection will not ensure that sufficient urine is available for the specimen.
Which action will the nurse implement to reduce the risk of catheter-associated urinary tract infection (CAUTI) in a male patient with an indwelling urinary catheter? A. Frequently pull on the drainage system tubing. B. Use the largest-size catheter possible. C. Clean the urinary meatus daily. D. Apply antiseptics to the urinary meatus.
C. Clean the urinary meatus daily. Rationale: To reduce the risk of CAUTI, daily cleansing of the urinary meatus is necessary. The drainage system tubing should not be pulled. Doing so could irritate the tissues, making infection more likely. The smallest-size catheter should be used, not the largest. A smaller catheter causes less urethral trauma and irritation. Perineal care should be performed with soap and water. Antiseptic solutions are not effective in preventing infection and should not be used for daily cleansing.
What is the primary reason the nurse ensures that a patient's indwelling urinary catheter drainage tubing is free of kinks? A. Kinks in the tubing cause the patient unnecessary discomfort. B. Kinks allow the drainage bag to become overly full. C. Kinks are associated with the development of urinary tract infection (UTI). D. Kinks result in scant, dark amber-colored urine.
C. Kinks are associated with the development of urinary tract infection (UTI). Rationale: Kinks in the drainage tubing obstruct the flow of urine into the drainage bag, which can cause UTI. Kinking of the drainage tubing interferes with proper urine drainage, perhaps making the patient uncomfortable; preventing infection, however, is more important than promoting comfort. Kinks in the drainage tubing do not result in an overly full drainage bag. In fact, they do the opposite (obstruct urine drainage into the bag), which can cause UTI. The development of scant, dark amber-colored urine is probably a result of dehydration, not kinked tubing. Kinks in the drainage tubing obstruct the flow of urine into the drainage bag, which can cause UTI.
When preparing to insert an indwelling urinary catheter in a male patient, it is important for the nurse to do what? A. Remove the cotton balls from the kit for later use. B. Advance the catheter 10 to 12 inches or until urine flows. C. Lubricate the first 5 to 7 inches of the catheter. D. Hold the penis at a 45-degree angle during insertion.
C. Lubricate the first 5 to 7 inches of the catheter. Rationale: The first 5 to 7 inches of the catheter is lubricated to ease insertion. The cotton balls will be used for cleansing. The catheter should be inserted 7 to 9 inches or until urine flows, not 10 to 12 inches. The penis is to be held at a 90-degree angle, not a 45-degree angle.
The nurse has delegated measurement of a patient's vital signs and catheter care to nursing assistive personnel (NAP). Which observation should the NAP report to the nurse immediately? A. Rectal temperature of 99.6° F B. Pulse rate of 88 beats per minute C. Redness noted on the external urethral meatus D. 200 mL of pale yellow urine in the drainage bag
C. Redness noted on the external urethral meatus Rationale: Redness surrounding the external urethral meatus is a sign of impaired skin integrity and should be reported to the nurse immediately. This rectal temperature is within normal limits; a catheterized patient's temperature should be closely monitored, however, since an elevated temperature may indicate that UTI has developed. This pulse rate is within normal limits; a catheterized patient's pulse rate should be closely monitored, however, since tachycardia may indicate that UTI has developed. This urine output and color are within normal limits; a catheterized patient's urine output should be monitored closely, however, to observe its characteristics (color, odor, cloudiness) and volume for signs of UTI.
A patient is admitted to your unit for dehydration. Which of the following assessments would the nurse identify as a possible sign of fluid imbalance? A. Heart rate at 80 beats per minute B. Capillary refill of less than 2 seconds C. Reduced turgor of the skin D. B/P of 118/78 mmHg
C. Reduced turgor of the skin Rationale: If the patient is well hydrated, the pinched skin will quickly return. If the patient has decreased elasticity or possible dehydration, a reduced turgor of the skin remains suspended, peaked, or "tented" for a few seconds, and then slowly returns to place. A heart rate of 80 beats per minute is within the normal range of 60 to 100 beats per minute. The capillary refill is cardiovascular assessment and not an assessment done for fluid imbalance. A blood pressure of 118/78 is within the normal range.
The nurse has completed the initial inspection of the patient's perineum and is preparing to insert an indwelling urinary catheter. Which action would the nurse complete next? A. Begin to establish a sterile field. B. Open and assemble the urine drainage bag. C. Remove soiled gloves, and perform hand hygiene. D. Center the drape over the patient's labia.
C. Remove soiled gloves, and perform hand hygiene. Rationale: This is the correct answer. The nurse's soiled gloves must be removed prior to setting up the sterile field. The nurse would establish the sterile field later, after performing hand hygiene and opening the catheter kit. The nurse would open and assemble the drainage bag later, after performing hand hygiene and opening the catheter kit. The nurse would drape the patient's labia later, after performing hand hygiene and opening the catheter kit.
While setting up the sterile field in preparation for inserting an indwelling urinary catheter, a male patient is incontinent of urine over most of the supplies. What action would the nurse take to reduce the patient's risk for infection? A. Rinse off the supplies that were contaminated with urine. B. Cleanse the patient's urinary meatus. C. Replace all contaminated supplies, and begin the process again. D. Change the patient's bed linens.
C. Replace all contaminated supplies, and begin the process again. Rationale: If the sterile field is contaminated while preparing to insert an indwelling urinary catheter, all contaminated supplies must be replaced and the process begun again. If the sterile field is contaminated while preparing to insert an indwelling urinary catheter, rinsing off the contaminated supplies and cleansing the patient's urinary meatus will not reduce the patient's risk for infection. If the sterile field is contaminated while preparing to insert an indwelling urinary catheter, is not sufficient to reduce the patient's risk for infection. It is appropriate to change the patient's bed linens, but doing so does not reduce the patient's risk for infection.
A female patient placed in the dorsal recumbent position for the insertion of an indwelling urinary catheter tells the nurse that she "doesn't feel comfortable in this position" and that her "back really hurts." What is the nurse's best response? A. Reassure the patient that the procedure will take only a few minutes. B. Promise to reposition the patient as soon as the catheter has been inserted. C. Reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip. D. Explain to the patient that the position will allow the catheter insertion to be more efficient.
C. Reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip. Rationale: This is the correct answer. The side-lying (Sims') position is an acceptable alternative that may be more comfortable for the patient. Reassuring the patient that the procedure will be brief, offering to reposition the patient after catheter insertion, and explaining that the position makes the procedure more efficient does not address the patient's comfort level during the catheter insertion.
What output will the nurse direct nursing assistive personnel (NAP) to measure for a hospitalized patient for whom I&O measurement is prescribed? A. Nasogastric tube drainage B. Chest tube drainage C. Urine collection drainage D. Ileostomy bag drainage
C. Urine collection drainage Rationale: The nurse may safely delegate the measurement of urine collection drainage to NAP. The nurse is responsible for monitoring nasogastric tube drainage, chest tube drainage, and ileostomy bag drainage.
The nurse instructs nursing assistive personnel (NAP) regarding proper technique for intermittent straight catheterization of a male patient. Which statement made by NAP indicates that the instruction was effective? A. "I'll help you set up the sterile field." B. "I'll get a sterile urine cup for you." C. "There are leg straps in the utility room." D. "I'll help keep his legs away from the sterile field."
D. "I'll help keep his legs away from the sterile field." Rationale: NAP can assist with intermittent straight catheterization by helping with patient positioning and comfort. NAP cannot assist with setting up a sterile field. A sterile urine cup is not used for intermittent straight catheterization. Leg straps are used for a continuous drainage bag and are not used for intermittent straight catheterization.
Which statement might the nurse make to nursing assistive personnel (NAP) before delegating the collection of a routine urine sample from a patient with an indwelling urinary catheter? A. "Does the patient understand why the specimen is needed and why we cannot obtain it from the Foley bag?" B. "See if the catheter is causing the patient any problems and if he is having any pain." C. "Please get two sterile urine collection containers from the utility room." D. "Let me know if the urine contains blood or sediment, or appears cloudy."
D. "Let me know if the urine contains blood or sediment, or appears cloudy." Rationale: This statement correctly focuses on the characteristics of urine that an NAP must report to the nurse. Patient education and pain assessment may not be delegated to NAP. A sterile container is not needed for a routine urinalysis specimen.
A patient has consumed three 100-mL cups of ice chips and 4 ounces of ginger ale. What will nursing assistive personnel (NAP) document as this patient's oral intake? A. 120 mL B. 170 mL C. 220 mL D. 270 mL
D. 270 mL Rationale: Three 100-mL cups of ice chips would be 150 mL of fluid, and 4 ounces of ginger ale would be 120 mL of fluid. The intake would be documented as 270 mL.
Which nursing action minimizes a patient's risk for injury during removal of an indwelling urinary catheter? A. Using a 5-mL syringe to deflate the balloon B. Using sterile scissors to cut the valve to deflate the balloon C. Tugging gently on the catheter to pull the balloon through the urethra D. Checking the documentation for the volume of fluid used to inflate the balloon
D. Checking the documentation for the volume of fluid used to inflate the balloon Rationale: Checking the volume of fluid used to inflate the balloon in order to ensure the balloon is completely deflated before removal is the nursing action that will minimize a patient's risk for injury during removal of an indwelling urinary catheter. A 5-mL syringe may not be large enough to accommodate the volume of fluid used to inflate the balloon. The valve on the catheter should not be cut to deflate the balloon. An inflated balloon should not be pulled through the urethra, no matter how gently. Doing so can damage the bladder and urethra.
Which action is most important in reducing the risk for infection in a patient receiving open intermittent irrigation of a urinary catheter? A. Attaching the urinary drainage bag to the bed frame B. Inspecting the drainage tubing for kinks C. Disposing of contaminated items after the procedure D. Cleaning the end of the drainage tubing with an antiseptic wipe before reconnecting it to the catheter
D. Cleaning the end of the drainage tubing with an antiseptic wipe before reconnecting it to the catheter Rationale: This is the correct answer. Swabbing the end of the drainage tubing with an antiseptic wipe before reconnecting it to the catheter reduces the number of pathogens that migrate from the tubing directly into the bladder. Attaching the urinary drainage bag to the bed frame below the level of the bladder would not specifically reduce the risk for infection in a patient receiving this type of irrigation. This action is appropriate for any patient with an indwelling urinary catheter. Inspecting the drainage tubing for kinks would not specifically reduce the risk for infection in a patient receiving open intermittent urinary catheter irrigation. It would, however, help to reduce pain caused by obstructed tubing. Disposing of contaminated items is appropriate after any procedure, to reduce the risk for infection to patient, nurse, other staff, and visitors. It is not, however, the most important way in which the nurse can reduce this patient's risk for infection.
What is the most effective way to prevent infection when providing catheter care for a patient? A. Properly dispose of soiled linen. B. Perform hand hygiene before positioning the patient. C. Secure the catheter to the patient's leg or abdomen. D. Cleanse from the meatus outward.
D. Cleanse from the meatus outward. Rationale: Securely holding the catheter and cleansing from the meatus outward is the most effective way to prevent infection when providing catheter care. Properly disposing of soiled linen is an infection control measure, but its effect in preventing infection during catheter care is negligible. Performing hand hygiene before positioning the patient is an infection control measure, but its effect in preventing infection during catheter care is negligible. Securing the catheter to the leg (in a female patient) or abdomen (in a male patient) will prevent the catheter from pulling on the bladder and will therefore reduce the risk of CAUTI; however, it is not the most important infection control measure listed.
Why does the nurse need to keep the urine sterile while obtaining a sample from an indwelling urinary catheter? A. Sterile technique protects the patient from microorganisms in the urine. B. Sterile technique protects the nurse from microorganisms in the urine. C. Sterile technique reduces the amount of pain caused by the procedure. D. Sterile technique ensures that microorganisms in the specimen are from the urine, and not the result of contamination.
D. Sterile technique ensures that microorganisms in the specimen are from the urine, and not the result of contamination. Rationale: The nurse will use sterile technique to obtain a urine specimen from an indwelling urinary catheter to ensure that any microorganisms in the specimen are from the urine, not from the patient's skin, the nurse's hands, or the environment. Protecting the patient from microorganisms in the urine is not the goal of using sterile technique. Protecting the nurse from microorganisms in the urine is not the goal of using sterile technique. Obtaining urine from an indwelling urinary catheter does not produce pain.
What is the best reason for the nurse to instruct a male patient to take slow, deep breaths during insertion of an indwelling urinary catheter? A. To increase oxygenation B. To reduce blood pressure C. To distract him D. To promote relaxation
D. To promote relaxation Rationale: The nurse would instruct a male patient to take slow, deep breaths during catheter insertion if the nurse felt resistance to the advancing catheter or if the patient reported pain. Deep breathing promotes relaxation, which might help to pass the catheter through the urinary sphincter. The nurse would not instruct a male patient to take slow, deep breaths during catheter insertion in order to increase oxygenation. The nurse would not instruct a male patient to take slow, deep breaths during catheter insertion in order to reduce blood pressure. Taking slow, deep breaths may distract the patient, but that is not the best reason for giving this instruction.
Why does the nurse cleanse a female patient's perineum before inserting an intermittent urinary catheter? A. To encourage the bladder to drain fully B. To encourage spontaneous voiding C. To prevent bowel elimination during the procedure D. To reduce the patient's risk of urinary tract infection
D. To reduce the patient's risk of urinary tract infection Rationale: The nurse cleanses a female patient's perineum before inserting an intermittent urinary catheter in order to reduce the patient's risk of infection. This action has no effect on bladder drainage or on bowel elimination. Perineal cleaning usually does not produce an urge to void spontaneously.
All of the following factors are known to increase the risk of urinary tract infection (UTI) except which one? A. History of fecal incontinence B. Use of an indwelling urinary catheter C. Drainage tubing is kinked D. Use of plain soap instead of an antiseptic cleanser for perineal hygiene
D. Use of plain soap instead of an antiseptic cleanser for perineal hygiene Rationale: Use of an antiseptic cleanser has not been shown to decrease the risk of catheter-associated urinary tract infection (CAUTI). Mild soap and warm water are adequate for perineal hygiene during catheter care. E. coli is the most common cause of CAUTI. E. coli colonizes the bowel; soiling from fecal incontinence therefore increases the risk of CAUTI. The risk of UTI increases with the use of an indwelling catheter, particularly if the catheter is left in place for more than a few days. Kinks in the drainage tubing obstructs the flow of urine into the drainage bag, which can cause UTI.