Cath Quiz
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. 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.
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. 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.
A patient with a suprapubic catheter is complaining of pain. What will the nurse do first to help this patient? A. Ensure that the patient is not lying on the drainage tubing. B. Instruct the patient to increase his or her oral fluid intake. C. Observe the rate of drainage in the urine collection bag. D. Notify the health care provider.
A. The nurse will first ensure that the patient is not lying on the drainage tubing because doing so could obstruct urine flow and cause pain. Increasing oral fluids will not reduce pain associated with a suprapubic catheter. The nurse would observe the rate of drainage in the collection bag only after ensuring that the flow of urine had not been obstructed by the weight of the patient's body on the tubing. Notifying the health care provider of the patient's complaint of pain would not be the nurse's first action.
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. 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. 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. 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.
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. 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 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 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.
Which statement might the nurse make to nursing assistive personnel (NAP) assigned to care for a patient with an established suprapubic catheter? A. "Tell me if the catheter site looks inflamed." B. "I need to know the patient's temperature each time it's taken." C. "Wear sterile treatment gloves when you remove the dressing." D. "Let me know if the patient's catheter is infected."
B. Temperature measurement can be delegated to NAP. This statement is appropriate for the nurse to make. Patient assessment cannot be delegated to NAP. Wearing sterile gloves is not needed when removing the dressing of an established suprapubic catheter. Patient assessment cannot be delegated to NAP. In addition, the dressing should be changed at least once per shift regardless of whether it looks soiled.
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. 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.
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. 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.
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. 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.
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. 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 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 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.
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 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.
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. 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.
Which nursing action reduces the risk for injury in a patient with a suprapubic catheter? A. Applying sterile gloves before cleansing the catheter insertion site B. Cleansing the skin surrounding the insertion site C. Securing the catheter to the abdomen D. Keeping the drainage bag above the level of the patient's bladder
C. Securing the catheter to the abdomen will reduce the patient's risk for injury by ensuring that excess tension is not applied to the catheter. Such tension could damage the bladder. Applying sterile gloves before cleansing the catheter insertion site will reduce the patient's risk for infection but will not prevent injury. Cleansing the skin around the insertion site will reduce the patient's risk for infection but will not prevent injury. Keeping the drainage bag above the level of the patient's bladder is incorrect. It should be kept below the bladder.
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. 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 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. 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.
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. 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 is the primary reason the nurse applies sterile gloves rather than clean ones when caring for a patient with a newly inserted suprapubic catheter? A. To protect the nurse and other patients from pathogens B. To collect a sterile urine sample C. To reduce the patient's risk for infection D. To reduce the patient's risk for injury
C. This is the correct answer. When providing care for a newly inserted suprapubic catheter, the nurse wears sterile gloves to reduce the risk of infecting the wound at the catheter insertion site. Although it is important to protect the nurse and other patients from pathogens, doing so is not the primary reason the nurse applies sterile gloves rather than clean ones when caring for a newly inserted suprapubic catheter. A sterile urine sample need not be collected from a patient with a newly established suprapubic catheter unless the provider has ordered one. Putting on gloves, sterile or clean, does not reduce the patient's risk for injury.
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. 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.
A newly inserted suprapubic catheter becomes dislodged. What action should the nurse perform first? A. Notify the health care provider. B. Apply pressure over the site. C. Cover the site with a sterile dressing. D. Help the patient into a side-lying position.
C. When a newly inserted suprapubic catheter becomes dislodged, the nurse's first action is to cover the site with a sterile dressing. The nurse would then notify the health care provider. Pressure need not be applied over the site, and doing so might further injure the wound tissue. There is no reason to move the patient into a side-lying position.
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. 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.
The nurse wants to delegate the application of a condom catheter to unlicensed assistive personnel (UAP). What must the nurse assess prior to delegating this task? 1. Assess whether the client has unique needs. 2. Measure the client's intake. 3. Assist the client out of bed to a chair. 4. Assess changes in the client's mobility status.
Correct Answer: 1 Rationale 1: Applying a condom catheter may be delegated to UAP. However, the nurse must determine whether the specific client has unique needs, such as impaired circulation or latex allergy, that would require special training of the UAP in the use of the condom catheter. Rationale 2: The nurse does not need to measure the client's intake before delegating the application of a condom catheter to UAP. Rationale 3: The nurse does not need to assist the client out of bed to a chair before delegating the application of a condom catheter to UAP. Rationale 4: The nurse does not need to assess changes in the client's mobility status before delegating the application of a condom catheter to UAP.
An older female client with a history of urinary tract infections has an indwelling urinary catheter. What should the nurse do to reduce this client's risk of developing an infection because of the catheter? Standard Text: Select all that apply. 1. Maintain a sterile closed drainage system. 2. Clean the peri-urethral area with antiseptics. 3. Ensure the catheter and tubing are not kinked. 4. Wash his or her hands before manipulating the catheter. 5. Keep the collection bag below the level of the bladder.
Correct Answer: 1, 3, 4, 5 Rationale 1: To prevent a urinary tract infection in the presence of an indwelling urinary catheter, the nurse should maintain a sterile closed drainage system. Rationale 2: Cleaning the peri-urethral area with antiseptics is an action that should be avoided. Rationale 3: To prevent a urinary tract infection in the presence of an indwelling urinary catheter, the nurse should maintain unobstructed urine flow by making sure the catheter and tubing are not kinked. Rationale 4: To prevent a urinary tract infection in the presence of an indwelling urinary catheter, the nurse should wash his or her hands before any manipulation of the catheter or collection system. Rationale 5: To prevent a urinary tract infection in the presence of an indwelling urinary catheter, the nurse should keep the collection bag below the level of the bladder at all times.
The nurse is documenting the insertion of a retention catheter for a client. What should be included in this documentation? Standard Text: Select all that apply. 1. Catheter size 2. Location of the drainage bag 3. Amount of urine that drained after insertion 4. Name of the physician who prescribed the insertion of the catheter 5. Client tolerance of the procedure
Correct Answer: 1, 3, 5 Rationale 1: The nurse should document the catheterization procedure, including the catheter size. Rationale 2: The nurse does not need to document the location of the drainage bag. Rationale 3: The nurse should document the amount of urine that drained after insertion. Rationale 4: The nurse does not need to document the name of the physician who prescribed the insertion of the catheter. Rationale 5: The nurse should document the client's tolerance of the procedure.
A client recovering from a transurethral resection of the prostate (TURP) with a three-way indwelling catheter expresses the need to urinate. Which action should the nurse take to help this client? 1. Deflate and then reinflate the balloon. 2. Irrigate the catheter. 3. Reposition the catheter. 4. Retape the catheter to the abdomen.
Correct Answer: 2 Rationale 1: Deflating and reinflating the balloon is not an option. The surgeon knows how much pressure is needed to control bleeding after surgery. Rationale 2: Blood clots give the client the sensation to urinate when they obstruct the urine outflow; therefore, irrigation will have to remedy the problem. Rationale 3: Repositioning the catheter would not be an option right after surgery. Rationale 4: The catheter is usually taped to the client's leg after a TURP and is not to be manipulated. This also controls bleeding after surgery.
The nurse is performing urinary catheterization for a client. After using the nondominant hand to separate the client's labia for cleansing, the nurse will maintain this hand as being 1. sterile. 2. contaminated. 3. able to evaluate the effectiveness of the catheter balloon. 4. clean.
Correct Answer: 2 Rationale 1: The hand is contaminated after touching the client's skin. Rationale 2: When performing urinary catheterization, the nondominant hand is considered contaminated once it touches the client's skin. Rationale 3: The hand should not be used to touch any equipment once it touches the client's skin. Rationale 4: The hand is contaminated, not clean, after touching the client's skin.
The nurse has completed closed irrigation of a client's retention catheter. What specific information should the nurse document about this procedure? 1. Number of ml of solution used to inflate the balloon of the catheter 2. Abnormal drainage, such as blood clots, pus, or mucous shreds 3. Location of the draining bag 4. Technique used to conduct the irrigation
Correct Answer: 2 Rationale 1: The nurse does not need to document the number of ml of solution used to inflate the balloon of the catheter, as the catheter already was in place. Rationale 2: The nurse should note any abnormal constituents, such as blood clots, pus, or mucous shreds. Rationale 3: The nurse does not need to document the location of the drainage bag. Rationale 4: The nurse does not need to document the technique used to conduct the irrigation.
Which nursing diagnosis would be appropriate for a client who has a retention catheter if the drainage bag is found lying on the floor? 1. Risk for Impaired Skin Integrity related to catheter placement 2. Risk for Infection related to improper handling 3. Self-Care Deficit related to presence of a retention catheter 4. Risk for Incontinence related to an obstruction
Correct Answer: 2 Rationale 1: There is a possibility of skin impairment with a catheter, but the emphasis here is on where the drainage bag was found. Rationale 2: The floor is the dirtiest place, so the drainage device should never be placed on the floor. Rationale 3: Even though a client has a catheter in place, it does not restrict one from providing self-care. The client may need some assistance. Rationale 4: The placement of a catheter prevents incontinence; it does not add to it. Patency of the catheter ensures flow, not obstruction.
The nurse is concerned that an older client with a retention catheter is developing a urinary tract infection. What assessment finding caused this concern? 1. Elevated blood pressure 2. Elevated heart rate 3. Confusion 4. Leg pain
Correct Answer: 3 Rationale 1: Elevated blood pressure is not a sign of urinary tract infection. Rationale 2: Elevated heart rate is not a sign of urinary tract infection. Rationale 3: In the older client, confusion can be an early sign of urinary tract infection. Rationale 4: Leg pain is not a sign of urinary tract infection.
Which nursing intervention is appropriate when caring for a client with a retention catheter? 1. Don sterile gloves. 2. Gently retract the labia majora away from the urinary meatus. 3. Observe urine in the drainage bag. 4. Retape the catheter to the thigh.
Correct Answer: 4 Rationale 1: Gloves are to be worn for cleaning but not sterile gloves. Rationale 2: When giving catheter care to a female, the labia minora is gently retracted away from the urinary meatus, not the labia majora. Rationale 3: The urine in the tubing should be observed, not the urine in the bag. Observing the urine in the tubing promotes accurate assessment of urine. Rationale 4: Retaping the catheter to the thigh after care is given prevents trauma and pain from tension and pulling.
A client is instructed on the care of an indwelling urinary catheter. Which returned demonstration by the client indicates that teaching has been effective? 1. The client empties the drainage bag once a day. 2. The client hangs the drainage bag on the towel rod. 3. The client refuses drinks one to two 8-ounce glasses of fluid each day. 4. The client takes a shower each day.
Correct Answer: 4 Rationale 1: The drainage bag should be emptied regularly, not just once a day but at least three times a day. Rationale 2: Hanging the drainage bag on the towel rod is too high. The drainage bag should be hung below the bladder. Rationale 3: Adequate amounts of fluids should be consumed to help prevent sediments and infections. Rationale 4: The client should take a shower rather than a tub bath because sitting in a tub allows bacteria to easily access the urinary tract.
The nurse is applying an external urinary device to a client. Before attaching the device to the drainage bag, what should the nurse do? 1. Wash his or her hands. 2. Document the client's tolerance of the procedure. 3. Instruct the client about the drainage system. 4. Ensure that the condom is not twisted.
Correct Answer: 4 Rationale 1: The nurse should wash his or her hands before and after the procedure. Rationale 2: The nurse should document after the procedure is completed. Rationale 3: The nurse should instruct the client about the drainage system after attaching the bag to the device. Rationale 4: The nurse should make sure that the tip of the penis is not touching the condom and that the condom is not twisted, because a twisted condom could obstruct the flow of urine.
The RN is admitting a client to the medical unit for a urinary disorder. Which physical assessment techniques should the nurse use in assessing this client's urinary system? 1. Auscultation and inspection 2. Inspection and percussion 3. Observation and auscultation 4. Palpation and observation
Correct Answer: 4 Rationale 1: The nurse will not use auscultation when assessing the client's urinary system. Rationale 2: The percussion technique is the least frequently used by nurses, and it would cause discomfort if this client is already uncomfortable with a kidney condition. The nurse should not make matters worse. Rationale 3: The nurse will not use auscultation when assessing the client's urinary system. Rationale 4: The hands and sense of touch are used with palpation to gather data along with observation or inspection, which visually allows the nurse to observe all responses and nonverbal behavior. It is also the most frequently used technique and the most convenient.
The nurse is determining tasks to delegate to unlicensed assistive personnel (UAP). Which task should the nurse question before delegating to this level of health care provider? 1. Measuring intake and output 2. Assessing vital signs for clients who are clinically stable 3. Performing complete morning care for a client recovering from a stroke 4. Inserting a urinary catheter into a client
Correct Answer: 4 Rationale 1: This skill can be delegated to UAP. Rationale 2: This skill can be delegated to UAP. Rationale 3: This activity can be delegated to UAP. Rationale 4: Due to the need for sterile technique and detailed knowledge of anatomy, insertion of a urinary catheter is not delegated to UAP.
A UAP has applied a condom catheter to a client. The nurse should document what information about this procedure? Standard Text: Select all that apply. 1. Number of ml of fluid used to inflate the balloon 2. Location of the drainage bag 3. Name of the UAP who applied the device 4. Time and date that the condom catheter was applied 5. Integrity of the penis
Correct Answer: 4, 5 Rationale 1: A condom catheter does not have a balloon that needs to be inflated. Rationale 2: The nurse does not need to document the location of the drainage bag. Rationale 3: The nurse does not need to document the name of the UAP who applied the device. Rationale 4: The nurse should document the application of the condom, including the time. Rationale 5: The nurse should document any pertinent observations, such as the integrity of the penis.
A client with an indwelling urinary catheter is prescribed to receive sterile normal saline bladder irrigation at 100 mL/hr. After an 8-hour shift the nurse measures the client's output as being 1425 mL. What is the client's urine output for the 8-hour shift? Standard Text: Calculate to the nearest whole number.
Correct Answer: 625 mL Rationale: The client is to receive 800 mL of bladder irrigant for the 8-hour shift. The nurse needs to subtract the bladder irrigant total from the total output, or 1425 - 800 = 625 mL. This is the client's urine output for the 8-hour shift.
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 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.
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. 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.
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. 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.
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. 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.
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. 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.
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. 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.