Catheterizing

The nurse is caring for a 72-year-old male client who requires insertion of an indwelling urinary catheter. What is an important assessment question for the nurse to ask the client prior to the procedure? a) "Do you have a history of diabetes?" b) "Do you have a history of recurrent urinary tract infections?" c) "Do you have a history of abdominal pain?" d) "Do you have a history of prostate problems?"

"Do you have a history of prostate problems?" Prostate enlargement usually begins around age 50 and could affect insertion of the indwelling urinary catheter. This would be important for the nurse to know prior to the procedure. A history of urinary tract infections would not affect the procedure of catheter insertion, as sterile technique should be used at all times. A history of abdominal pain or diabetes should not have any bearing on the procedure itself.

What instruction would the nurse give the client before removing an indwelling urinary catheter? a) "Take several quick breaths." b) "Take several slow, deep breaths." c) "Hold your breath until the tube is removed." d) "Forcefully blow out your breath upon removal of the tube."

"Take several slow, deep breaths." The nurse would ask the client to take several slow, deep breaths when pulling out the tubing of an indwelling catheter. Slow, deep breathing helps to relax the sphincter muscles.

When applying a condom catheter to a client, how much space would the nurse leave between the tip of the penis and the end of the condom? a) 3 to 4 in (7.5 to 10 cm) b) ½ to 1 in (1.25 to 2.5 cm) c) 2 to 3 in (5 cm to 7.5 cm) d) 1 to 2 in (2.5 to 5 cm)

1 to 2 in (2.5 to 5 cm)

A nurse is preparing to initiate a continuous closed bladder irrigation for a client. The nurse has completed the preparation steps. The sterile irrigation bag is prepared, labeled, and flushed. The tubing is clamped, and the end cover has been replaced. The nurse has put on gloves and then completes the next steps listed below. Place them in the order that the nurse would perform them. Use all options.

1) Cleanse the irrigation port with an alcohol swab. 2) Aseptically attach irrigation tubing to irrigation port of the three-way catheter. 3) Check to make sure the clamp on the drainage tubing is open. 4) Release the clamp o the irrigation tubing. 5) Regulate the flow at the determined drip rate.

A nurse is administering intermittent closed-catheter irrigation to a client. Place the following steps in the correct order. Use all options.

1)Cleanse the access port on the catheter with an antimicrobial swab. 2)Clamp or fold the catheter tubing below the access port. 3)Attach the syringe to the access port on the catheter using a twisting motion. 4)Gently instill solution into the catheter. 5)Remove the syringe from the access port. 6)Unclamp or unfold the tubing and allow the irrigant and urine to flow into the drainage bag.

The nurse is collecting a urine sample from the port of the client's catheter drainage tubing. How much urine is generally collected for a sample unless otherwise indicated by the facility? a) 20 mL b) 5 mL c) 10 mL d) 15 mL

10 mL Generally, 10 mL is adequate for a urine specimen; the nurse would check facility requirements.

When placing an indwelling urinary catheter, where should the nurse hold the catheter? a) 4 to 5 in (10 to 12.5 cm) from the tip of the catheter b) at the tip of the catheter c) 2 to 3 in (5 to 7.5 cm) from the tip of the catheter d) 1 in (2.5 cm) from the tip of the catheter

2 to 3 in (5 to 7.5 cm) from the tip of the catheter By holding the catheter 2 to 3 in (5 to 7.5 cm) from the tip, it allows for adequate control while decreasing risk of contamination. The catheter should not be held directly at the tip or at 1 in (2.5 cm) to facilitate insertion. Holding the catheter 4 to 5 in (10 to 12.5 cm) from the tip will not allow for good control and increases risk of contamination.

A nurse is caring for a client receiving a continuous closed bladder irrigation. The client's urine output prior to initiating the irrigation was 350 mL. After approximately 6 hours, the nurse empties the drainage bag and records an amount of 1,200 mL. The irrigation is running at 100 mL/hour as prescribed. The nurse documents a urine output of which amount?

600 ml

A nurse is providing care to a client who is receiving a continuous closed bladder irrigation. The nurse inspects the solution bag labeled as bladder irrigant and notes that the solution was started this morning at 6:30 am. The nurse would plan to discard this solution and hang new bag of irrigant solution if the current solution was not completely infused by which time?

6:30 am tomorrow

For which client would clamping or bending back a catheter drainage tube to collect a urine specimen most likely be contraindicated? a) A client post bladder surgery. b) A client with diabetes. c) A client with hypertension. d) A client with a neurological disorder.

A client post bladder surgery. Clamping of the catheter drainage tubing for extended periods of time causes overdistention of the bladder and is contraindicated in certain clients, such as a client post bladder surgery. Diabetes, hypertension, and neurological disorders would not be contraindications for this step in the procedure.

The nurse is placing an indwelling urinary catheter for a female client. Once urine drains into the catheter tubing, what should the nurse do next? a) Advance the catheter an additional 2 to 3 in (5 to 7.5 cm). b) Retract the catheter 3 in (7.5 cm). c) Rotate the catheter gently. d) Stop any further insertion.

Advance the catheter an additional 2 to 3 in (5 to 7.5 cm). Advancing the catheter an additional 2 to 3 in (5 to 7.5 cm) ensures placement in the bladder and facilitates balloon inflation without damaging the urethra. The nurse should not stop advancing the catheter immediately when urine is noted in the catheter tubing or retract the catheter to ensure placement in the bladder and facilitate balloon inflation without damaging the urethra. The catheter would not need to be rotated unless resistance is met.

The nurse is performing an irrigation of the client's catheter using a closed system. What should the nurse use to disinfect the aspiration port?

An antimicrobial swab.

The nurse is performing an irrigation of the client's catheter using a closed system. What should the nurse use to disinfect the aspiration port? a) Normal saline on a gauze square. b) An antimicrobial swab. c) Water and soap on a washcloth. d) Rinseless cleanser on a washcloth.

An antimicrobial swab. The nurse would wipe the aspiration port with an alcohol or other antimicrobial swab to disinfect it. Cleaning the port reduces the risk of introducing organisms into the closed system. Saline, soap, water, or rinseless cleanser does not disinfect the port.

The nurse is applying a condom catheter to a client who is urinating frequently and unable to control his urination following surgery. Which accurately describes the correct procedure for this application? a) Apply the condom sheath tightly around the penis to prevent leakage. b) Apply the condom sheath securely enough to prevent leakage, but not so tight as to restrict blood flow. c) Apply the condom sheath loosely on the penis to prevent blood flow restriction. d) Apply the condom sheath loosely enough so that one finger can be placed between the penis and the condom catheter.

Apply the condom sheath securely enough to prevent leakage, but not so tight as to restrict blood flow.

The nurse is collecting a urine sample from an indwelling urinary catheter. Prior to cleaning the aspiration port, what would be the appropriate nursing action? a) Clamp the tubing above the port. b) Bend the drainage tubing back on itself distal to the port. c) Turn off the drainage system. d) Make sure the tubing is not kinked

Bend the drainage tubing back on itself distal to the port. Clamping the catheter drainage tubing or bending it back on itself, distal to the port, ensures the collection of an adequate amount of fresh urine. There is not a drainage system that has a knob to turn it off and clamping the tubing above the port would not allow urine into the port for collection. Making sure the tubing is not kinked may help the flow of urine, but it does not ensure the collection of enough fresh urine for a sample.

The nurse is caring for a female client with an indwelling urinary catheter. The nurse notes that the catheter is not draining. What is the correct action by the nurse? a) Check the catheter tubing for kinks or twisting. b) Remove the current catheter and apply a condom catheter. c) Push the catheter upward toward the bladder. d) Refill the catheter balloon with more sterile water.

Check the catheter tubing for kinks or twisting. The catheter should first be checked for kinks or twisting that may be causing it not to drain. The catheter should not be pushed upward as this could cause damage to the urethra. The balloon should not be refilled with water as this could cause damage to the urethra. The catheter may need to be replaced if kinks or twisting are not evident. A condom catheter is only indicated for a male client.

The nurse is irrigating a client's urinary catheter using a closed system. What action would the nurse perform after cleansing the access port on the catheter?

Clamp or fold the catheter tubing below the access port.

The nurse is irrigating a client's urinary catheter using a closed system. What action would the nurse perform after cleansing the access port on the catheter? a) Clamp or fold the catheter tubing below the access port. b) Place a waterproof pad under catheter and aspiration port. c) Pour sterile solution into sterile basin. d) Remove catheter from device.

Clamp or fold the catheter tubing below the access port. After cleansing the access port on the catheter, the nurse would clamp or fold the catheter tubing below the access port to direct the irrigating solution into the bladder, thereby preventing flow into the drainage bag. The other steps listed above would be performed prior to cleansing the access port.

When obtaining a urine specimen from an indwelling urinary catheter, the nurse places a label on the specimen container. How should the nurse check the information on the specimen label? a) Compare it to the client identification band. b) Check the label with the laboratory doing the testing. c) Check the specimen label against the health care provider's prescription. d) Ask the client whether the information on the specimen label is correct.

Compare it to the client identification band. When collecting a urine specimen from a client, the nurse would compare the specimen label to the client identification band. This ensures the specimen is labeled correctly for the right client. The nurse would not rely upon the client's confirmation of the label or check the label with the health care provider prescription or lab at this point in the procedure.

The nurse is caring for a female client with an indwelling urinary catheter. The client reports sudden pain and urethral spasm. What is the best action by the nurse? a) Reposition the client toward either side. b) Deflate the balloon, remove the catheter, and replace. c) Add more sterile water to the catheter balloon. d) Push the catheter upward toward the bladder.

Deflate the balloon, remove the catheter, and replace. Sudden pain and urethral spasm can indicate that the catheter balloon may be lodged in the urethra. Balloon should be deflated, and the catheter should be removed and replaced. Pushing on the catheter or adding more water to the balloon can cause further urethral spasm and damage. Repositioning the client would not adequately address the problem. The best course of action is to remove the current catheter and insert a new one, using sterile technique.

The nurse meets resistance when inserting a Foley catheter into a client. What would be the recommended action in this situation? a) Do not force the catheter. b) Apply moderate force to advance the catheter. c) Notify the health care provider of the obstruction. d) Rotate the catheter a full turn and direct it towards the bladder.

Do not force the catheter. If resistance is met when inserting a Foley catheter, the nurse should not force the catheter as this could cause trauma to the structures. The nurse could rotate the catheter 1⁄2 turn and try to advance it again. If this does not work, the nurse should notify the health care provider.

The nurse has finished collecting a urine specimen from the client's indwelling urinary catheter. What would the nurse do with the collected specimen to prepare it to be sent to the lab? a) Transfer the urine from the syringe into a test tube for analysis. b) Empty the urine from the syringe into a specimen cup with a lid. c) Place the syringe filled with the urine specimen inside a biohazard bag. d) Empty half of the urine from the syringe into a specimen cup and dispose of the rest of the urine.

Empty the urine from the syringe into a specimen cup with a lid. After collecting a urine specimen from an indwelling urinary catheter, the nurse would remove the syringe from the port, slowly inject the urine from the syringe into the specimen container, replace the lid on the container, and place the syringe in the sharps container. The specimen container would be labeled and placed in a biohazard bag for transport to the lab.

When monitoring a client with a condom catheter, the nurse finds that the catheter will not stay on the client. What would be the initial recommended step for this situation? a) Ensure that the condom catheter is the right size. b) Document the incident and notify the health care provider. c) Lubricate the penis and reapply the condom catheter. d) Discard the old catheter and apply a new one.

Ensure that the condom catheter is the right size.

When removing an indwelling urinary catheter from a client, the nurse prepares to deflate the catheter balloon. Which is the proper method for deflating the balloon? a) Insert a syringe into the balloon inflation port and allow the water to come back by gravity. b) Insert a syringe and instill air into the balloon until a "popping" noise is heard. c) Insert a syringe into the balloon inflation port and aspirate half the amount of sterile water in the balloon. d) Gently pull the tubing forward, allowing pressure to deflate the balloon.

Insert a syringe into the balloon inflation port and allow the water to come back by gravity. The nurse, when deflating the balloon on an indwelling urinary catheter, would insert the syringe into the balloon inflation port and allow the water to come back by gravity. Alternatively, the nurse could insert the syringe into the balloon inflation port and aspirate all of the sterile water that was used to inflate the balloon. All of the water must be removed to prevent injury to the client. The tube would not be pulled out until the balloon is deflated, and air would not be instilled into the tube.

A client with an indwelling urinary catheter has a PRN prescription for intermittent catheter irrigation. The nurse notices there is no urine coming out of the catheter and that the client is complaining of bladder pain and pressure. What might the nurse do to rectify this situation?

Irrigate the catheter with normal saline to restore patency.

A client with an indwelling urinary catheter has a PRN prescription for intermittent catheter irrigation. The nurse notices there is no urine coming out of the catheter and that the client is complaining of bladder pain and pressure. What might the nurse do to rectify this situation? a) Irrigate the catheter with normal saline to restore patency. b) Instill air into the catheter to remove any blockages. c) Remove the catheter and notify the health care provider. d) Replace the catheter with a new one.

Irrigate the catheter with normal saline to restore patency. Indwelling catheters sometimes require irrigation, or flushing, with solution to restore or maintain patency of the drainage system. Sediment, debris, or even blood clots may block the catheter. The nurse would irrigate the catheter with normal saline, as prescribed by the health care provider. Air would not be instilled into the catheter to remove blockages. Because there is a prescription for irrigation, irrigation would be tried prior to removing the catheter and replacing it with a new one or notifying the health care provider.

The nurse is inserting an indwelling urinary catheter for a female client. The nurse notes that no urine flow is obtained and that the catheter appears to be in the vaginal orifice. What is the next step by the nurse? a) Leave the misplaced catheter in place as a marker and repeat the procedure with a new catheter. b) Leave the misplaced catheter in place as a marker and perform an ultrasound bladder scan. c) Remove the misplaced catheter and repeat the procedure with the misplaced catheter. d) Remove the misplaced catheter and repeat the procedure with a new catheter.

Leave the misplaced catheter in place as a marker and repeat the procedure with a new catheter. Leaving the catheter in place can help mark the correct area for the nurse. A new catheter should be used in to prevent cross-contamination and decrease the risk of infection. A bladder ultrasound is not indicated in this case.

What is the most important advantage of using a condom catheter versus an indwelling catheter? a) Less potential for infection. b) Can be used to obtain a sterile urine specimen. c) Less potential for skin breakdown. d) Provides more privacy for the client.

Less potential for infection

The nurse is applying a condom catheter to an older adult client who has become incontinent of urine following hip surgery. In what position would the nurse place the client when applying this device? a) Lying flat b) Lying on side c) Standing d) Sitting upright

Lying flat

The nurse is obtaining a urine specimen from a client with an indwelling urinary catheter. Which must the nurse wear during this procedure? a) Gown b) Nonsterile gloves c) Mask d) Sterile gloves

Nonsterile gloves Personal protective equipment (PPE) such as a mask and gown would only be put on if indicated. Nonsterile gloves are always used in the procedure to reduce the transmission of microorganisms.

The nurse is inserting an indwelling urinary catheter for a female client. Despite several tries, the nurse cannot get the catheter to advance into the bladder. What is the next action by the nurse? a) Assess the catheter tubing for kinks or twisting. b) Notify the client's health care provider. c) Chart in the medical record that the client refused the procedure. d) Have the client drink 8 ounces of water, wait 30 minutes, and retry.

Notify the client's health care provider. If attempts have been made to advance the catheter, the nurse should stop and notify the client's health care provider. Drinking water or checking for tubing kinks would not affect catheter advancement. There is nothing to indicate that the client refused the procedure.

The client experiences leakage around the condom catheter. Which action does the nurse perform? a) Insert an indwelling urinary catheter. b) Ask the client to use the urinal to void. c) Obtain the correct supplies and replace it. d) Place an incontinence brief on the client.

Obtain the correct supplies and replace it.

The nurse is inserting an indwelling urinary catheter for an uncircumcised male client. Prior to filling the catheter balloon, how far should the nurse insert the catheter? a) to the catheter bifurcation b) 15 centimeters c) halfway to the catheter bifurcation d) 10 centimeters

to the catheter bifurcation The male urethra is about 20 cm long. By inserting the catheter all the way to the catheter bifurcation, this minimizes the risk of inadvertently inflating the balloon while it is still in the urethra.

The nurse is positioning a client for the removal of an indwelling urinary catheter. Where should the nurse stand during the procedure? a) At the foot of the bed. b) On the client's left side, if left handed. c) At the head of the bed. d) On the client's right side, if left handed.

On the client's left side, if left handed. The nurse would adjust the bed to a comfortable working position and stand at the client's left side, if left handed and at the right side, if right handed. Proper positioning allows access to the site and ensures proper body mechanics for the nurse performing the procedure.

The nurse irrigates an indwelling urinary catheter through a closed system. Why is this preferable to opening the catheter?

Opening the catheter can lead to contamination and infection.

The nurse irrigates an indwelling urinary catheter through a closed system. Why is this preferable to opening the catheter? a) Opening the catheter can lead to contamination and infection. b) Once the catheter is opened, it is difficult to keep it patent. c) Once a catheter is opened, it cannot be re-closed. d) Opening the catheter can lead to leakage.

Opening the catheter can lead to contamination and infection. Irrigating an indwelling urinary catheter through a closed system prevents the system from becoming contaminated, which could lead to infection. Opening the system does not normally lead to leakage or blockages and opened catheters can be closed again. However, due to the risk of infection, a closed system is always preferable.

A nurse is providing care to a client who is receiving a continuous closed bladder irrigation. The nurse notes that the hourly drainage is less than the amount of the irrigation being given. Which actions by the nurse would be most appropriate? Select all that apply.

Palpate the client's bladder for distention. Check the tubing for any kinking.

What are important elements for the nurse to remember regarding proper attachment of an indwelling urinary catheter for a male client? Select all that apply. a) Attach drainage bag to raised side rail. b) Leave slack in catheter to ensure ease in client leg movement. c) Secure catheter tubing to the client's inner thigh or lower abdomen. d) Place drainage bag below the level of the bladder. e) Position catheter under leg behind client.

Place drainage bag below the level of the bladder. Leave slack in catheter to ensure ease in client leg movement. Secure catheter tubing to the client's inner thigh or lower abdomen. The catheter tubing should be secured to the client's inner thigh or lower abdomen to prevent pulling. The drainage bag should never be attached to the side rail to prevent pulling. There should be slack left with catheter to ensure ease in client leg movement. By placing drainage bag below the level of the bladder, the flow of urine will be facilitated. The catheter should not be positioned under the leg behind the client to prevent catheter kinking and twisting and to vacillate the unobstructed flow of urine.

What would the nurse do with an indwelling urinary catheter immediately after removing it? a) Place it in a biohazard bag. b) Place it in the packaging in which it came. c) Place it in a wash basin prior to disposal. d) Place it on the waterproof pad and wrap it in the pad.

Place it on the waterproof pad and wrap it in the pad. The nurse would remove the indwelling catheter, place it on the waterproof pad, and wrap it in the pad. After removing gloves and making the client comfortable, the nurse would put on clean gloves, and remove and dispose of the equipment according to facility policy. The catheter would not be placed immediately in a biohazard bag. It would not be placed in a wash basin. The original packaging for the catheter would not be available when the catheter is removed, nor would this action be appropriate.

The nurse is caring for a female client with an indwelling urinary catheter. Upon entering the room, the nurse notices that the client has placed the catheter bag next to her in bed. The client's bladder is distended, and she reports of bladder pain. What is the correct action by the nurse? a) Place the catheter bag lower than the client and assess for the flow of urine. b) Raise the head of the client's bed. c) Administer PRN dose of pain medication to the client. d) Remove and replace the indwelling urinary catheter.

Place the catheter bag lower than the client and assess for the flow of urine. Urine may not be flowing from the catheter to the bag, causing bladder distention. The bag should be placed lower than the client and the nurse should assess for the flow of urine. Administering a PRN dose of pain medication may be prescribed but will not address bladder distention due to poor urine flow into the catheter bag. Raising the head of the bed could cause more bladder pressure and will not alleviate the problem. The bag should be lowered first before the catheter is replaced.

A nurse is administering continuous closed-bladder irrigation to a client. After performing this intervention, the nurse observes that the irrigation solution is not flowing at the prescribed rate. Which actions should the nurse take? Select all that apply.

Raise the bag 3 to 6 in (7.5 to 15 cm). Check the tubing for kinks or pressure points. Open the clamp all the way.

When removing an indwelling urinary catheter from a client, the nurse notices resistance while attempting to pull out the catheter. What would be the immediate intervention in this situation? a) Reattach the syringe to the port, aspirate again, and reattempt catheter removal. b) Instill 10 mL air into the inflation port to reinflate the balloon and aspirate again. c) Pull harder on the tubing as long as the client can tolerate it. d) Irrigate the aspiration port with 20 mL sterile saline.

Reattach the syringe to the port, aspirate again, and reattempt catheter removal. If resistance is met while attempting to pull out an indwelling catheter, the nurse would stop pulling the catheter, reattach the syringe to the balloon inflation port, and aspirate again to make sure all the sterile water has been removed. The nurse would then reattempt the catheter removal. If resistance is still felt, the nurse would notify the health care provider. The nurse would not irrigate the aspiration port with 20 mL sterile saline, and air should not be used to reinflate the balloon.

A nurse is caring for a female client with an indwelling urinary catheter. While performing client assessment, the nurse notes urine leaking around the catheter. What is the correct response by the nurse? a) Reposition the client toward either side. b) Remove the current catheter and reinsert a new one. c) Push the catheter upward toward the bladder. d) Refill the catheter balloon with more sterile water.

Remove the current catheter and reinsert a new one. The catheter should not be pushed upward as this could cause damage to the urethra. The balloon should not be refilled with water as this could cause damage to the urethra and the integrity of the balloon may be damaged. Repositioning the client would not adequately fix the problem. The best course of action is to remove the current catheter and insert a new one, using sterile technique.

The nurse is inserting an indwelling urinary catheter for an uncircumcised male client. After the catheter has been anchored properly, what is an important step for the nurse? a) Cleanse the foreskin vigorously after catheter placement. b) Replace the foreskin into its non-retracted position. c) Check the foreskin for signs of infection. d) Ensure that the foreskin stays retracted as far back as possible.

Replace the foreskin into its non-retracted position. The foreskin will need to be replaced into its natural position. Leaving it retracted could increase swelling and stricture, making it painful for the client. Therefore, the foreskin should not stay retracted. Monitoring for signs of infection in a catheterized client is important, but the foreskin would not show immediate signs of infection right after catheterization. The foreskin should not need to be vigorously cleansed as cleaning has already occurred.

A nurse is performing a catheterization of a male client. The nurse meets resistance when advancing the catheter. What should the nurse try before stopping the procedure and notifying the health care provider? a) Increase force and point catheter downward. b) Stop for a moment and have the client take several slow, deep breaths. c) Fully remove the catheter and retry procedure. d) Twist the catheter vigorously from side to side while advancing it.

Stop for a moment and have the client take several slow, deep breaths. By stopping for a moment and having the client take several slow, deep breaths the urethra may relax, making advancing easier. Twisting the catheter vigorously or increasing the force of the catheter could cause damage to the urethra or prostate. The catheter should not be removed and reused, because this increases the risk of contamination.

The nurse is inserting an indwelling urinary catheter for a female client. The client moves her leg accidently, contaminating supplies. What is the correct action by the nurse? a) Replace sterile gloves before re-handling supplies. b) Recleanse the perineal area and proceed with procedure. c) Tell the client to lay as still as possible to expedite procedure. d) Stop the procedure, obtain new supplies, and restart procedure.

Stop the procedure, obtain new supplies, and restart procedure. The supplies are contaminated and, therefore, new supplies should be obtained before the procedure is restarted. Recleansing the perineal area only does not address the contaminated supplies. The client may need help to position legs, but the procedure will still need to be started with new supplies. Replacing sterile gloves only does not address the contaminated supplies.

The nurse is obtaining a urine specimen from a client with an indwelling urinary catheter. From what part of the system would the nurse get the urine for the specimen? a) The drainage bag. b) The port. c) The catheter. d) An open tube.

The port. : Indwelling catheter drainage tubes have special sampling ports in the tubing for removal of urine for testing. The nurse would not open the drainage system to obtain urine samples from the tube, and urine specimens would not be taken from the catheter drainage bag because the urine is not fresh.

When collecting a urine sample from the port of the client's catheter drainage tubing, the nurse inserts the syringe into the aspiration port, slowly aspirates enough urine for the specimen, and removes the syringe. What would be the nurse's next step? a) Disconnect the drainage tubing. b) Unclamp the drainage tubing. c) Document the procedure in the client chart. d) Clean the aspiration port with an alcohol wipe.

Unclamp the drainage tubing. After collecting the urine specimen, the nurse would remove the syringe from the port and unclamp the drainage tubing. This prevents overextension of the client's bladder and injury to the bladder. The tubing would not be disconnected, the aspiration port is cleansed prior to inserting the needle, and documentation is completed at the end of the procedure.

The nurse clamps the catheter drainage tubing to collect a urine specimen from a client's indwelling urinary catheter. How long can the nurse leave the tubing clamped to obtain a sufficient amount of urine? a) Up to 25 minutes. b) Up to 15 minutes. c) Up to 30 minutes. d) Up to 20 minutes.

Up to 30 minutes. The nurse can clamp the catheter drainage tubing or bend it back on itself, distal to the port, for up to 30 minutes to obtain a sufficient amount of urine, unless contraindicated. Clamping for an extended period of time can lead to overdistention of the bladder.

A nurse has just removed an indwelling catheter from a client. Which common complications of urinary function should the nurse monitor for in the client, after removal of an indwelling catheter? Select all that apply. a)

Urinary retention Difficulty voiding Burning or irritation while voiding

The nurse is inserting an indwelling urinary catheter for a male client. How should the nurse properly cleanse the area prior to catheter insertion? a) Using a circular motion, move from the glans up to the meatus of the penis. b) Using a circular motion, move from the meatus down the glans of the penis. c) Using a back-and-forth motion, move from the right side of the glans up to the meatus of the penis. d) Using a back-and-forth motion, move from the left side of the glans up to the meatus of the penis.

Using a circular motion, move from the meatus down the glans of the penis. Moving from the meatus down the glans toward the base of the penis prevents bringing microorganisms to the meatus. Other methods increase chances of bringing contamination of microorganisms toward the meatus.

The nurse receives a prescription to remove an indwelling urinary catheter from a client who is pregnant and on bed rest. The nurse should be sure to maintain which safety protocol when performing this procedure? a) Sterile technique. b) Clean technique. c) Surgical asepsis. d) Transmission precautions.

b) Clean technique. Removal of an indwelling catheter is performed using clean technique. Sterile technique (surgical asepsis) is used when inserting an indwelling catheter. Transmission precautions would be used only in cases where it is indicated. Hand hygiene prevents the spread of microorganisms.

Prior to indwelling urinary catheter insertion for a female client, how should the nurse cleanse the perineal area? a) Wipe from sacrum upward toward urinary orifice. b) Wipe from left side to right side. c) Wipe from right side to left side. d) Wipe from above urinary orifice downward toward sacrum.

Wipe from above urinary orifice downward toward sacrum. Wiping from above urinary orifice downward toward sacrum helps to cleanse the perineum from least to most contaminated area. The other options do not cleanse the perineum from least to most contaminated area.

When obtaining a urine specimen from an indwelling urinary catheter, how would the nurse clean the aspiration port? a) With a surgical scrub. b) With an alcohol wipe. c) With sterile saline. d) With soap and water.

With an alcohol wipe. The nurse would cleanse the aspiration port with an alcohol wipe and allow the port to air dry prior to inserting the needle into the port. Cleaning the port with alcohol deters entry of microorganisms when the needle punctures the port.

The nurse is caring for a male client with an indwelling urinary catheter. Where does the nurse correctly place the bag of the catheter? a) attached to the bed itself lower than the client b) lying in the bed on either side of the client c) lying on the floor lower than the client d) attached to the side rail closest to the client

attached to the bed itself lower than the client The catheter bag should be attached to the bed itself and positioned lower than the client. If it is attached to the side rail, it could become pulled or dislodged. The bag should not be placed in bed with the client or on the floor.

The nurse is caring for a female client with an indwelling urinary catheter. The nurse notes that the catheter is not draining. What is the first action by the nurse? a) Push the catheter upward toward the bladder. b) Check the catheter tubing for kinks or twisting. c) Refill the catheter balloon with more sterile water. d) Remove the current catheter and reinsert a new one.

b) Check the catheter tubing for kinks or twisting. The catheter should first be checked for kinks or twisting that may be causing it not to drain. The catheter should not be pushed upward as this could cause damage to the urethra. The balloon should not be refilled with water as this could cause damage to the urethra and the integrity of the balloon may be damaged. The catheter may need to be replaced if kinks or twisting are not evident.

A client reports a burning sensation when urinating for the first time following the removal of an indwelling urinary catheter. In this situation, what would be the nurse's intervention? a) Schedule a urinalysis for the client. b) Inform the client that this is normal for the first few voids. c) Monitor the client for urinary retention. d) Inform the health care provider of a possible urinary tract infection.

b) Inform the client that this is normal for the first few voids. Following removal of a urinary catheter, the client may experience burning or irritation the first few times he or she voids, due to urethral irritation. This would not be the time to notify the health care provider of a possible urinary tract infection unless the symptoms continue. A nurse does not schedule urinalysis; this is the responsibility of the health care provider. If the catheter was in place for more than a few days, the nurse would monitor for urinary retention, but this would not cause a burning sensation.

The nurse prepares for insertion of an indwelling urinary catheter for a female client. Prior to catheter insertion, what should the nurse do? Select all that apply. a) Help the client void prior to procedure. b) Question the client about any allergies to latex or iodine. c) Confirm the medical prescription for indwelling catheter insertion. d) Have the client drink an 8-ounce glass of water. e) Assess the client's degree of physical limitations.

b) Question the client about any allergies to latex or iodine. c) Confirm the medical prescription for indwelling catheter insertion. e) Assess the client's degree of physical limitations. The nurse should confirm the medical prescription for indwelling catheter insertion prior to the procedure. By assessing the client's degree of physical limitations, the nurse can determine how much the client can help during the procedure and what other assistance may be needed. The client does not need to drink water prior to the procedure as this will not change anything with the procedure or its outcomes. The client should be questioned about any allergies to latex or iodine and changes should be made to the procedure based on any client allergies. The client should not void prior to the procedure and this could, in fact, affect the presence of urinary return when assessing proper catheter placement.

While performing client assessment, the nurse notes urine leaking around the indwelling catheter of a male client. The nurse tells the client that the catheter will need to be placed. The client asks why it cannot "just be repositioned." What is the best response by the nurse? a) "New equipment is better than something that has been in place a while." b) "We can try that first but, if the catheter is still leaking, it will need to be replaced." c) "Repositioning the catheter could cause damage to the urethra or prostate." d) "The catheter is probably worn out and a new one is needed."

c) "Repositioning the catheter could cause damage to the urethra or prostate." Repositioning the catheter could cause damage to the urethra or prostate and, thus, the catheter should be replaced. By merely telling the client that a new catheter is "needed or better" does not given an adequate explanation. The nurse should not try repositioning the client first, because this will not adequately address the problem.

The nurse is caring for a male client who requires insertion of an indwelling urinary catheter. The client is quite anxious about the procedure and asks the nurse what he can do during the procedure to help it go more smoothly. What is the best response by the nurse? a) "Try not to think about it and it will go pretty quickly if you are not stressed." b) "Most people tolerate the procedure very well without any complications." c) "I will try and insert the catheter as quickly as possible for you." d) "Taking deep breaths and bearing down during the procedure may make passage of the catheter through the urethra easier."

d) "Taking deep breaths and bearing down during the procedure may make passage of the catheter through the urethra easier." By instructing the client to take deep breaths and bear down during the procedure, the passage of the catheter through the urethra may be easier. The nurse should insert the catheter with a steady motion but should not try to insert it as quickly as possible to avoid urethral damage. Telling the client "not to think about it" or that "most people" do fine devalues the client's fears instead of helping to alleviate them.

The nurse is removing an indwelling catheter from a client on bed rest following bowel surgery. At what point in the procedure would the nurse deflate the balloon? a) After cutting the inflation port. b) After cutting the irrigation tube. c) After removing the catheter. d) Before removing the catheter.

d) Before removing the catheter. The nurse would completely deflate the balloon on an indwelling urinary catheter prior to removal to prevent irritation and damage to the urethra and meatus. The nurse would not cut the inflation port or the irrigation tube when removing the catheter.

The nurse is caring for a client with an indwelling urinary catheter. For this client, the nurse plays a key role in prevention of which most common complication? a) chronic urinary retention b) uncontrolled suprapubic pain c) unsuppressed bladder spasms d) catheter-associated urinary tract infections

d) catheter-associated urinary tract infections Catheter-associated urinary tract infections are the most common complication of urinary catheters. The nurse plays a key role in prevention of this complication from sterile catheter insertion technique to regular catheter care. The client with an indwelling urinary catheter should not regularly be experiencing uncontrolled suprapubic pain or unsuppressed bladder spasms. If the client does, this should be reported. A client with an indwelling urinary catheter should not have urinary retention if the catheter is draining properly.

The nurse prepares for insertion of an indwelling urinary catheter for a male client. The nurse is right-handed. Where should the nurse stand to perform the procedure? a) at the client's left lower leg b) at the end of the client's bed c) on the client's left side d) on the client's right side

on the client's right side : Proper positioning allows for ease of use of the dominant hand for catheter insertion. Therefore, the nurse should not stand on the left side of the client. The nurse should not be positioned at the end of the bed as this will not allow for ease of use of the dominant hand for catheter insertion.