Ch 36 Urinary Bladder
To promote drainage of a client's Foley catheter, which intervention would be most important for the nurse to implement?
Confirming the catheter tubing is not lying under the client
Painful or difficult urination
Dysuria
increased incidence of voiding
Frequency
Glycosuria
presence of sugar in the urine.
The nurse is preparing to catheterize a patient who is incontinent of urine following bladder surgery. What fact should the nurse keep in mind when performing catheterization?
The bladder normally is a sterile cavity.
Which of the following is a recommended guideline when catheterizing the female urinary bladder?
Once urine drains, advance the catheter another 2 to 3 inches (2.5-5 cm).
A patient informs the nurse that he is concerned about dribbling and incontinence of small amounts of urine after the removal of his indwelling urinary catheter. The nurse is aware that the catheter was in place for three weeks prior to being removed. Which of the following is the nurse's best response to the patient?
"It will take a little while for the bladder to re-establish control, and an accident is not unusual."
The nurse has an order to obtain a urine specimen from a client with an indwelling Foley catheter. Which of these supplies would the nurse need to gather?
Antiseptic swab 10-mL (milliliter) syringe Sterile specimen container
The nurse has an order to obtain a 24-hour urine from a client. Which of the following instructions would be accurate for collection of the specimen?
"Discard your first urine and begin the collection after that."
24hr urine output is less than 500mL; synonyms are complete kidney shutdown or renal failure.
Anuria
Anticoagulants may cause ______________, leading to a pink or red color in the urine.
Hematuria
A client states that urinary incontinence has become a problem and asks the nurse how to help control or alleviate this problem. Which statement by the nurse would be accurate
"Performing Kegel exercises can help with muscle strengthening.
The nurse is caring for a client with a prescription for a midstream urine specimen. The nurse would provide which information to the client?
"Void a small amount, stop, and discard it."
When planning care for a client with a Foley catheter, which actions should the nurse include? (SELECT ALL THAT APPLY)
*Encourage fluid intake, unless contraindicated *Maintain a closed urinary catheter system.
Keep the tip of the tubing on a condom catheter:
1-2 inches beyond the tip of the penis.
What makes up the DETRUSOR MUSCLE of the urinary bladder?
3 layers of muscle called the: inner longitudinal layer middle circular layer outer longitudinal layer
The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder.
4- Clean each labial fold, then the area directly over the meatus. 1-Open sterile catheterization tray using sterile technique. 2- Don sterile gloves 3- Open all sterile supplies. 5-Slowly insert the lubricated catheter into the urethra. 6-Advance the catheter until there is a return of urine.
A nurse is caring for an elderly client at his home. The client has had a condom catheter applied. Which of the following describes a condom catheter?
A flexible sheath that is rolled around the penis
The nurse has an order to obtain a urine specimen from a client with an indwelling Foley catheter. Which of these supplies would the nurse need to gather?
A patient with an enlarged prostate is unable to void. A sterile urine specimen is needed from an acutely confused client. A client is in septic shock and highly unstable.
Which of the following situations warrant urinary catheterization?
A patient with an enlarged prostrate is unable to void. A sterile urine specimen is needed from an acutely confused client A client is in septic shock and highly unstable
A nurse collects a clean-catch specimen from a client at a health care facility. Which of the following statements describes a clean-catch urine sample?
A sample of urine that is considered sterile
The nurse is inserting a urinary catheter into a female patient and has begun to inflate the balloon, an action that has caused the patient to wince and cry out in pain. Consequently, the nurse should do which of the following?
Deflate the balloon, insert the catheter further, and slowly attempt reinflation.
The nurse is providing teaching to a client who is being discharged to home with an indwelling urinary catheter in place. What information is important for the nurse to discuss with the client?
The catheter can be connected to a smaller leg bag for ambulation.
A nurse uses a portable bladder ultrasound device to assess bladder volume for a patient who is unable to void. Which of the following accurately states information needed to interpret the results?
The device must be programmed for the gender of the patient by pushing the correct button on the device.
Which of the following accurately describes a guideline when inserting an indwelling catheter?
Avoid irrigation unless needed to relieve an obstruction.
What is another name for urination?
Micturition
During his stay in the hospital, a male client has established a pattern of maintaining urinary continence during the day, but he is experiencing incontinence at night. What intervention should the nurse implement in this client's care?
Condom Catheter at night
The nurse is caring for a client with urinary incontinence who has a prescription for a postvoid residual (PVR) collection. 45 mL of amber urine is returned via PVR. Which appropriate action would the nurse take with this data collection?
Document the finding.
A nurse is caring for a client with an external condom catheter. Which of the following is a guideline for applying and caring for this type of catheter?
Fasten the condom securely enough to prevent leakage without constricting the blood vessels.
Which of the following is an accurate guideline to follow if there is not an immediate flow of urine after a catheter has been inserted?
Have the patient take a deep breath, which helps to relax the perineal and abdominal muscles.
A nurse is caring for an elderly client who has been prescribed a condom catheter. What potential problems related to the use of condom catheter should the nurse monitor in the client?
Inability to control urinary elimination Excoriation of the skin in the glans area Restricted blood flow to the glans tissue
A nurse drains the bladder of a client by inserting a catheter for 5 minutes. What type of catheter would the nurse use in this instance?
Intermittent urethral catheter
Which of the following is an advantage of using a condom catheter for a male patient who has frequent episodes of urinary incontinence?
It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters.
You are attempting to insert a urinary catheter into a female patient's bladder and realize the catheter has been inserted into the vagina. Which of the following actions is most appropriate?
Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter.
What is a normal finding for a postvoid residual collection (PVR)
Less than 50mL
Awakening at night to urinate
Nocturia
A nurse is caring for a client who is catheterized following a surgery of the prostate. When caring for the client, the nurse performs a continuous irrigation of the catheter. Which of the following interventions should the nurse perform when providing continuous irrigation?
Prime the tubing with the solution
A nurse is performing an intermittent closed catheter irrigation on a client and realizes that the tubing was not clamped before introducing the irrigation solution. What would be the nurse's response to this situation?
Repeat the irrigation
A physician orders a long-term continuous drainage system to monitor a chronically ill client. What type of catheter would best suit this client's needs?
Suprapubic catheter *Suprapubic catheters are recommended for long-term continuous drainage because they are associated with a decreased risk of contamination with organisms from fecal material, the elimination of damage to the urethra, a higher rate of client satisfactions, and a lower risk of UTIs
What catheter would the nurse use to drain a patient's bladder for short periods (5 to 10 minutes)?
Straight catheter
A nurse is collecting a urine specimen for urinalysis. What factors should the nurse consider when performing this procedure?
Strict aseptic technique must be used when collecting and handling urine specimens. A clean-catch specimen of urine may be collected in midstream Sterile urine specimens may be obtained by catheterizing the patient's bladder.
The nurse mentor is observing a novice nurse prepare to insert an indwelling catheter for a female client with urinary retention. The mentor would intervene, if which action by the novice nurse is noted?
The novice selected an 18 French Foley catheter to insert . -->the smallest available normal size is a 14f-16f with a 5-10mL balloon
You are inserting a urinary catheter into a 63-year-old male patient and encounter resistance. Which of the following is the most likely cause of the resistance?
The patient has an enlarged prostate
Upon assessment of the urine in a patient's indwelling urinary catheter drain bag, the nurse notes the urine to be dark yellow. This assessment finding indicates which of the following?
The patient is underhydrated
Which of the following statements about suprapubic catheters is true?
They are often preferred over an indwelling urethral catheter for long-term urinary drainage. --> they are surgically inserted through a small incision above the pubic area.
What type of catheter is used for a continuous irrigation in order to maintain a closed system.
Triple Lumen Catheter
Urinary catheterization is the most common cause of hospital acquired infection.
True
Use of indwelling urinary catheter leads to the loss of bladder tone.
True
The nurse is choosing a collection device to collect urine from a nonambulatory male patient? What would be the nurse's best choice?
Urinal
The period when urine if produced normally but is not excreted completely from the bladder.
Urinary Retention
A nurse is inserting a catheter into a female urinary bladder. Which nursing action is performed correctly?
Use dominant hand to inflate the catheter balloon, and inject entire volume of sterile water supplied in prefilled syringe.
The nurse collects a urine sample from a client for urinalysis. What would the nurse document as a normal characteristic?
light yellow color