BSN 205-10 (Urinary Catheterization)

Testing the balloon by injecting fluid from the prefilled sterile water syringe into the balloon port is...

no longer a common practice. Testing the balloon may stretch the balloon and lead to damage, causing increased trauma on insertion.

Failure to reduce the foreskin after catheterization can result in _________________________________.

paraphimosis (constriction of the foreskin)

The 8 French, 3-mL balloon, latex catheter is a _____________________.

pediatric catheter

Lifting the penis to a ___________________ position and applying light traction is done to straighten the urethra.

perpendicular; traction

Moving the ________________ prevents the skin from becoming irritated.

securement device

The NAP should measure and record intake and output ______________________________.

so urine trends can be assessed

The nurse is reviewing urinary catheter care with a newly hired nursing assistive personnel (NAP). Which statement made by the NAP indicates further instruction is needed? "Urinary catheter care is a clean procedure; sterile gloves are unnecessary." "The bedside drainage bag should only be emptied when it is full." "The securement device that anchors the catheter should be reapplied." "Catheter care can be delegated to nursing assistive personnel."

"The bedside drainage bag should only be emptied when it is full."

The NAP is applying a condom catheter to the patient. The patient asks, "What is the purpose of the skin preparation solution?" The NAP correctly responds: "It is used before condom sheath application as an adhesive to hold the condom catheter on." "It is an antiseptic to clean pathogens from the area before applying the condom catheter." "The skin preparation solution prevents skin irritation and should be dry before the condom catheter is applied." "The skin preparation solution helps the condom catheter to go on more easily, reducing friction, and should still be wet when the sheath is applied."

"The skin preparation solution prevents skin irritation and should be dry before the condom catheter is applied."

A patient had an indwelling catheter for 3 weeks. The patient had the catheter removed 3 hours ago and now complains of having to go to the bathroom frequently and that it is painful to void. Which instruction is appropriate for the nurse to give the patient? "This is a normal occurrence after having a catheter in place for more than several days." "It sounds like you have a UTI. I will notify your health care provider." "I will need to inspect your perineal area and wash and dry the area." "If these symptoms continue, I will notify your health care provider to see if we can reinsert the catheter."

"This is a normal occurrence after having a catheter in place for more than several days."

A patient returned from urological surgery with closed continuous bladder irrigation. The patient's vital signs are within normal limits. The patient's wife voices concern regarding the "bloody-red" appearance of the drainage. What is the nurse's best response? "This is normal at this time; the drainage will become lighter and appear blood tinged in 2 to 3 days." "I will notify the health care provider immediately of this unexpected finding." "You don't need to worry, we are doing everything possible for your husband. He is in good hands." "What you are seeing in the drainage bag really isn't blood, but rather a type of drainage."

"This is normal at this time; the drainage will become lighter and appear blood tinged in 2 to 3 days."

The patient is to have intermittent irrigation of a double-lumen urinary catheter. The patient asks why the nurse is kinking the drainage tubing and putting a rubber band on it. What is the nurse's best response? "This will prevent air from entering your bladder which could cause bladder spasms." "This prevents the irrigating solution from going down into your drainage bag rather than into your bladder." "Clamping the drainage tubing helps your bladder to maintain muscle tone so you will not become incontinent." "Clamping the drainage tubing is a safety measure to prevent bacteria from the drainage bag to enter your bladder during irrigation."

"This prevents the irrigating solution from going down into your drainage bag rather than into your bladder."

A 53-year-old patient is being treated for hypertension and a history of thrombophlebitis (blood clots). She comes to the clinic complaining, "I have to get up all night to go to the bathroom, and I think my urine looks orange!" What is the nurse's best response? "It sounds like you may have a urinary tract infection." "Your high blood pressure is adversely affecting your kidneys." "Have you tried to restrict your fluid intake?" "What medications are you taking and when?"

"What medications are you taking and when?" The nurse should first assess the patient's medication history before making any interpretation. The patient may be taking diuretics before going to bed or taking other medications that can change the urine's color.

During application of the condom catheter, the adhesive strip falls to the floor. What is the nurse's best action? Obtain silk tape because it has some ability to stretch. Use paper tape in a spiral fashion because it is nonallergenic. Use plastic IV tape because it is waterproof preventing slippage. Obtain another adhesive strip from condom catheter kit.

Obtain another adhesive strip from condom catheter kit.

The nurse has received an order to insert an indwelling catheter in a 24-year-old female patient. Which catheter would be most appropriate for this patient? 14 Fr 5 mL balloon 10 Fr 3 mL balloon 16 Fr 30 mL balloon 20 Fr 5 mL balloon

14 Fr 5 mL balloon

A 68-year-old female patient is admitted for knee replacement surgery with an expected hospital stay of 2 weeks. She has no known allergies. The health care provider has ordered an indwelling catheter to be inserted preoperatively. Which catheter should the nurse choose? 14 French, 5-mL balloon, latex catheter. 18 French, 5-mL balloon, latex catheter. 8 French, 3-mL balloon, latex catheter. 16 French, 30-mL balloon, silicon catheter.

14 French, 5-mL balloon, latex catheter.

Most adults require a _____________________ catheter; it is usually best to begin with the smaller size.

14 to 16 French

If a patient's indwelling catheter is removed at 0900, the patient should be due to void by: 1900 to 2100 (7:00 PM to 9:00 PM) 1100 to 1200 (11:00 AM to 12:00 PM) 1500 to 1700 (3:00 PM to 5:00 PM) 0930 (9:30 AM)

1500 to 1700 (3:00 PM to 5:00 PM) The patient should be due to void in 6 to 8 hours, or by 3:00 to 5:00 PM. If the patient fails to void, nursing measures should be taken (i.e., assess for bladder fullness, provide privacy, assist to normal voiding position, run water). If unsuccessful, the health care provider should be notified.

A 40-year-old male patient has been admitted for abdominal surgery. He has no history of prostate problems. The health care provider has ordered that the patient be catheterized. Which of the following would be an appropriate-size catheter for this patient? 8 French, 3-mL balloon 12 French, 5-mL balloon 16 French, 5-mL balloon 16 French, 30-mL balloon

16 French, 5-mL balloon

A _______________________ is for continuous bladder irrigation (CBI).

30 mL balloon

Which of the following is the best example of documentation on a patient with a urinary catheter? A. Catheter care provided; no encrustation noted. Urinary catheter patent and draining clear yellow urine to bedside drainage bag. B. Catheter care provided. 14 French catheter intact with approximately 30 mL urine in bedside drainage bag. C. Unable to palpate urinary bladder. Patent denies discomfort; indwelling catheter draining well. D. Patient instructed on signs and symptoms of UTI and how to prevent while catheterized.

A Documentation should include the appearance of the urine whether clear or cloudy or with sediment and color.

A _____________ balloon is a common size balloon for the adult. Latex and rubber catheters are recommended for use up to _________________.

5-mL; 3 weeks

Four patients had a bladder scan for PVR. For which of the following patients would further investigation be required? A patient with a PVR of 25 mL. A patient with PVR measurements of 125 mL and 150 mL. A patient with a PVR of 50 mL. A patient with a prescan volume of 250 mL and a PVR volume of 30 mL.

A patient with PVR measurements of 125 mL and 150 mL. A PVR volume of less than 50 mL is considered normal. Two or more PVR measurements greater than 100 mL require investigation. It would be an expected finding for a PVR volume to be less than the prescan void. Prescan volume is the amount of urine the patient voids attempting to empty the bladder completely before having a PVR measured by either bladder scan or straight catheterization.

Which of the following could be considered negligence? A regular condom catheter is removed every 3 days. Clean gloves are worn to apply a condom catheter. Allowing a family caregiver to apply the condom catheter. Avoiding the use of barrier creams on the penile shaft.

A regular condom catheter is removed every 3 days.

A nurse inserting an indwelling urinary catheter in a female patient advances the catheter and obtains clear yellow urine. What is the next action the nurse should take? Inflate the balloon with the prefilled syringe of sterile water in the balloon port. Pull gently back on the catheter approximately 1 inch or until resistance is met. Advance catheter another 1 to 2 inches and inflate balloon. Ask patient to bear down as if to void.

Advance catheter another 1 to 2 inches and inflate balloon. The female urethra is short. The appearance of urine indicates that the catheter tip is in the bladder. Advancement of the catheter ensures that the inflation balloon is in the bladder and not the urethra. The nurse pulls back gently on the catheter after the balloon is inflated. The nurse may ask the patient to bear down as if to void when initially inserting the catheter; this maneuver relaxes the external urethral sphincter.

Reasons for lack of urine after inserting a straight catheter include: (Select all that apply.) A. The catheter is outside of the bladder. B. The catheter is inserted in the vagina rather than in the urethra of a female patient. C. The male patient's prostate is preventing urine from exiting the bladder. D. Urethral spasms are preventing urine from exiting the body. E. The patient's bladder is distended.

AB The catheter may be in the urethra ahead of the internal sphincter of the bladder. Catheter malposition may be a cause of lack of urine. Urethral spasms may cause discomfort but will not prevent urine flow with an established catheter. An enlarged prostate may hinder catheter insertion but once inserted does not prevent urine from exiting the body. Bladder distention would indicate a full bladder, which once catheterized should result in urine output.

The nurse works on a surgical unit. For which of the following patients would a nurse expect to perform a bladder scan? (Select all that apply.) A. A patient who had an indwelling urinary catheter removed 8 hours ago and voided 30 mL once since it was removed. B. A patient who complains she is having urinary incontinence and never had this problem before. C. A patient who is postoperative for urological surgery. D. A patient who was placed on diuretic therapy to reduce peripheral edema. E. A patient who reports a change in urine color.

ABC A bladder scanner is used to assess bladder volume whenever inadequate bladder emptying is suspected, such as after the removal of indwelling urinary catheters, in the evaluation of new-onset urinary incontinence, and after urological surgery. Diuretic therapy is not an indication for a bladder scan. A change in urine color requires further assessment because it may be due to a change in medicine, or it could be due to hematuria, but it is not an indication of inadequate bladder emptying.

A nursing student is watching a nurse catheterize a female patient with an indwelling catheter. Which of the following, if it occurs, indicates a break in sterile technique? (Select all that apply.) A. The nurse inserts the urinary catheter, and when urine does not return, removes the catheter and makes a second attempt to locate the urethra with the same catheter. B. The nurse lubricates the catheter and places it back into the sterile tray when it uncoils and touches the bed. C. After the nurse cleans the labia, the labia become slippery and closed as the nurse attempts to obtain a clear view of the urethra. D. The nurse advances the catheter another 2.5 to 5 cm (1 to 2 inches) after urine appears, releases the labia, and holds on to the catheter with the nondominant hand. E. The nurse uses forceps and a new cotton ball when cleansing the area, wiping along the far labial fold, the near labial fold, and directly over the center of the urethral meatus.

ABC The nurse should never use the same catheter to attempt an insertion a second time because the catheter is contaminated. The nurse should leave the first catheter in the vagina as a landmark and insert another sterile catheter. If the catheter touches the bed, the nurse should obtain a new sterile catheter because the first one has become contaminated. If closure of the labia occurs during cleansing, the cleansing procedure should be repeated because the area has become contaminated. Once urine appears, the nurse should advance the catheter to ensure bladder placement. The nurse is correct in releasing the labia and holding on to the catheter with the nondominant hand because bladder or sphincter contraction may cause accidental expulsion of the catheter. The dominant hand is used to inflate the balloon of the catheter. The nurse also used the correct technique in cleansing the area.

The nurse has a sterile urinary catheter and sterile gloves. Choose the remaining equipment the nurse will need to insert a straight urethral catheter: (Select all that apply.) A. Sterile cotton balls. B. Antiseptic solution. C. Sterile urinary collection bag. D. Water-soluble lubricant. E. Sterile forceps.

ABDE Straight urinary catheterization requires aseptic (sterile) technique. The nurse will need five to six sterile cotton balls soaked in antiseptic solution, such as Betadine, to reduce the number of microorganisms present on perineal area. Sterile forceps are used to pick up the antiseptic-saturated cotton balls. Water-soluble lubricant is used to ease insertion of the catheter. A sterile urinary collection bag is used for an indwelling catheter. Sterile water or normal saline in a syringe is used to inflate the balloon on an indwelling catheter and is unnecessary for a straight catheter.

The nurse is preparing continuous bladder irrigation. Which of the following actions by the nurse would be appropriate? (Select all that apply.) A. Performing hand hygiene and donning clean gloves. B. Priming the infusion tubing with irrigating solution. C. Clamping the drainage tubing below the injection port. D. Calculating urinary output as the amount of irritant infused subtracted from the amount in the drainage bag. E. Monitoring and emptying the drainage bag as needed.

ABDE There is no need to clamp the drainage tubing with a continuous bladder irrigation; this is done with intermittent closed catheter irrigation. All other actions are appropriate.

A nurse is performing preoperative teaching for a patient who is having urological surgery. The nurse informs the patient he will likely require closed bladder irrigation following the surgery. The patient asks what the purpose is for bladder irrigation. What would be a correct response by the nurse? (Select all that apply.) A. "Bladder irrigation may be used to instill medication into the bladder." B. "The irrigating solution helps kill any bacteria that may be present in the bladder." C. "Irrigating the bladder prevents any clots or sediment from blocking urinary drainage." D. "Bladder irrigation is one method used to treat pain after urological surgery." E. "Irrigating the bladder applies pressure to prevent bleeding at the operative site."

AC Bladder irrigation may be performed to instill medication (usually done as an intermittent irrigation) into the bladder, or to provide a continuous flow to prevent clot formation. Both intermittent and continuous bladder irrigation may be used to maintain patency for urinary drainage.

Which of the following demonstrate that further teaching is required to prevent an infection related to being catheterized? (Select all that apply.) A. An elderly female patient carries her urinary drainage bag like a purse under her arm as she ambulates. B. A patient drinks an entire pitcher of water over the period of 1 day. C. As a patient is being transferred in a wheelchair, he places the drainage bag in his lap. D. The NAP places a patient's drainage bag on a lowered side rail or on the floor. E. A female patient keeps her catheter secured to her thigh with tape.

ACD The urinary drainage bag should be kept below the level of the bladder to prevent reflux of urine into the bladder. Patients should be instructed to carry the drainage bag below the level of the bladder and to secure the drainage bag to the side of the wheelchair below the level of the bladder during transfer. The urinary drainage bag should never be placed on a bedside rail because it could accidentally be raised to a height higher than the level of the bladder and urine could reflux into the bladder. The urinary drainage bag should never be placed on the floor; this is to avoid having bacteria enter the system through the drainage port. If allowed, fluids should be encouraged. The catheter should be secured to the patient to prevent trauma to the urethra. Swelling of tissues can impair urine flow and place the patient at further risk for urinary tract infection.

The nurse is teaching the male patient and family caregiver about the advantages of a condom catheter. Which of the following should be included in the teaching? (Select all that apply.) A. It is relatively safe and noninvasive. B. It ensures complete bladder emptying. C. It is a convenient method of draining urine. D. It is used for male patients who are incontinent. E. It may remain in place for several weeks at a time. F. It carries less risk of developing a UTI than an indwelling catheter.

ACDF

Identify the indicators of a UTI: (Select all that apply.) A. Fever. B. Urinary drainage. C. Complaints of pain with urination (dysuria). D. Hypothermia. E. Lower abdominal pain. F. Cloudiness of the urine.

ACEF Fever is an indication of infection. Complaints of pain or burning are indicative of a UTI as urine passes over inflamed tissues. The patient may feel abdominal pressure and discomfort with a UTI. Urine should be clear; cloudy urine may indicate the presence of bacteria or white blood cells in the urine.

As part of catheter insertion assessment, where should the nurse palpate? At the costovertebral angle. Above the symphysis pubis. Starting at the right iliac crest and moving upward along the midclavicular line. Midway between the xyphoid process and symphysis pubis.

Above the symphysis pubis.

The nurse is catheterizing a female patient and obtains a clear amber urine return. As the nurse begins to inflate the balloon, the patient complains of pain and resistance is felt. What is the nurse's best action? Allow fluid to flow back into syringe and advance the catheter a little more before attempting to reinflate. Have the patient take slow deep breaths, inhaling through the nose and exhaling through the mouth. Lift penis to position perpendicular to patient's body, and apply light traction. Advance catheter to bifurcation of the drainage tube and balloon inflation port.

Allow fluid to flow back into syringe and advance the catheter a little more before attempting to reinflate.

A male patient with back and lower abdominal injuries from a motor vehicle accident is unable to void. His health care provider has ordered the insertion of a catheter to determine the amount of residual urine and then to remain in place to assist him with voiding during this post-trauma period. What type of urinary catheter should the nurse anticipate using? A condom catheter A Coudé catheter An indwelling catheter A straight catheter

An indwelling catheter It is acceptable to use an indwelling catheter in this case to obtain the residual urine amount. This reduces the number of catheterizations to one, especially since the health care provider has ordered the catheter to remain in place to assist the patient with voiding until the pain subsides.

The nurse is inserting an indwelling Foley catheter in a male patient. The nurse asks the patient to bear down as if to void and slowly inserts the catheter through the urethral meatus. The nurse advances the catheter and meets resistance. What is the nurse's best initial action at this time? Ask the patient to take slow deep breaths while inserting the catheter slowly. Withdraw the catheter and notify the health care provider. Apply more force to insert the catheter inward. Remove the catheter, apply more lubricant, and reinsert.

Ask the patient to take slow deep breaths while inserting the catheter slowly.

The nursing instructor is reviewing the renal system and urinary catheterization with her students. Which statement, if made by a nursing student, indicates that further instruction is needed? A. "The urinary tract is considered to be sterile." B. "The nurse may use clean technique to insert an indwelling catheter." C. "The urge to void is felt when the bladder contains 150 to 200 mL in an adult." D. "The minimum average hourly urine output is 30 mL."

B

Which of the following actions associated with urinary catheterization could cause a potential problem? A. Attaching the bedside drainage bag to the bed frame. B. Keeping the foreskin retracted after catheterization. C. Failing to test the balloon by injecting fluid from prefilled sterile water syringe into the balloon port before insertion. D. Cleansing the far labial fold, the near labial fold, and directly over the center of urethral meatus using a new swab with each area.

B

The nurse has inserted a catheter 7.5 cm (3 inches) in a female patient and obtains no urine return even though her bladder is distended. What action should the nurse take at this time? A. Remove the catheter and have another nurse attempt to catheterize the patient. B. Leave the catheter in the vagina as a landmark and insert another sterile catheter. C. Remove the catheter and reinsert into the urethra. The nurse may straighten the urethra by inserting one finger of a sterile-gloved hand inside the vagina and applying gentle pressure upward. D. Inflate the balloon and reassess in 1 hour for urine return in the bedside drainage bag.

B There should be a urine return because the patient's bladder is distended. If no urine appears, the catheter may be in the vagina. If misplaced, the nurse should leave the catheter in the vagina as a landmark where not to insert, and insert another sterile catheter. The nurse may straighten the urethra by inserting one finger of a sterile gloved hand inside the vagina and applying gentle pressure upward; however, a new sterile catheter should be used.

The nurse is reviewing how to perform a bladder scan for determining postvoid residual (PVR) with nursing assistive personnel (NAP). Which of the following statements, if made by the NAP, indicates understanding? (Select all that apply.) A. "This test requires the patient to follow fluid intake restrictions." B. "I will measure and record the patient's intake and output." C. "I will perform the bladder scan and then have the patient urinate." D. "I will apply ultrasound gel above the patient's symphysis pubis." E. "I should point the scanner head downward toward the bladder."

BDE

Which of the following steps should you take before removing fluid from the balloon in an indwelling urinary catheter? (Select all that apply.) A. Attach a 2-mL syringe to the balloon port and aspirate the fluid. B. Attach a 10 mL or larger syringe to the balloon port and allow the water to passively fill the syringe. C. Attach a 10- or 20-mL syringe to the balloon port and forcibly aspirate the water. D. Cut the balloon port and allow the water to slowly drain into a sterile basin. E. Gently aspirate the syringe plunger if water remains in the balloon.

BE A 10 mL or larger syringe should be attached to the balloon port, and the water should be allowed to passively fill the syringe. Gentle aspiration, if necessary, is appropriate.

The nurse is catheterizing a male patient. Which of the following demonstrates correct understanding of the procedure? (Select all that apply.) A. The patient is placed in a dorsal recumbent position for urinary catheter insertion. B. The nurse applies sterile gloves before opening the antiseptic solution and lubricant. C. The patient is placed in a supine position with legs slightly abducted. D. The nurse cleans the urethral meatus using a circular motion beginning at the meatus and working outward in a spiral pattern.

BCD Male patients should be placed in a supine position with legs slightly abducted. The nurse then cleans the urethral meatus using a circular motion from meatus down to the base of the glans. This should be repeated 3 times using a clean cotton ball/stick each time. Everything in the catheter kit is sterile, therefore opening the antiseptic solution and lubricant would not contaminate the sterile gloves.

Identify the procedures that may be delegated to NAP: (Select all that apply.) A. Insertion of a straight catheter B. Perform a bladder scan C. Application of a condom catheter D. Care of an indwelling catheter E. Insertion of an indwelling catheter

BCD Trained NAP may apply condom catheters, perform a bladder scan, and care for an indwelling catheter.

Which of the following are true regarding the impact of aging related to urinary elimination? (Select all that apply.) A. The elderly are better able to concentrate urine than the middle-aged adult. B. Aging can affect continence if the patient experiences impaired mobility or decreased muscle tone. C. The elderly are less likely to experience urinary frequency than middle-aged adults because they tend to drink less. D. The elderly are at increased risk for urinary tract infection because of retained urine in the bladder. E. It is part of the normal aging process for elderly patients to become incontinent.

BD The very young and very old are less able to concentrate urine, placing them at risk for dehydration. The elderly are at an increased risk of urinary incontinence if they have impaired mobility that prevents them from getting to the bathroom in time or from manipulating buttons and zippers. Weak abdominal and pelvic floor muscles impair bladder contraction. Decreased muscle tone increases the risk for urinary incontinence. However, urinary incontinence is not a normal physiological result of the aging process. Urination frequency increases with age with decreased bladder tone. Because the bladder cannot contract as effectively, an older person often retains urine in the bladder after voiding (residual urine). This places the patient at increased risk for bacterial growth and development of urinary tract infections (UTIs).

A nurse is explaining the procedure for inserting an indwelling urinary catheter. Which of the following explanations regarding anchoring of the catheter would be most accurate? A. An indwelling catheter tube is secured to a female patient's abdomen to prevent accidental dislodgment. B. An indwelling catheter tube is secured to the male patient's inner thigh with a strip of nonallergenic tape or a commercial tube holder. C. It is important to anchor the catheter tubing to minimize the risk for urethral trauma and bladder spasms from traction and to prevent accidental dislodgment. D. When securing the catheter tubing, slack in the catheter should be avoided to prevent movement and possible tissue injury.

C Securing the catheter will minimize the accidental dislodgment of the catheter. It also minimizes the risk for bleeding, trauma, meatal necrosis, and bladder spasms from pressure and traction. In male patients, catheter tubes are attached to the lower abdomen or to top of thigh; in female patients, tubes are attached to the inner thigh. Allow slack in catheter so movement does not create tension on catheter.

A patient with a double-lumen urinary catheter has an order for closed intermittent catheter irrigation. The nurse performs hand hygiene, applies clean gloves, draws up 50 mL of room temperature irrigating solution into a sterile syringe, and places a sterile cap on the end. The nurse wipes the catheter and drainage tubing junction with an alcohol swab, disconnects the catheter from the drainage tube, inserts the needleless syringe, and gently instills the irrigating solution at an even, steady rate. The nurse reconnects the drainage tubing and observes the fluid return for color and any sediment or clots. What aspect of skill performance, if any, was in error? A. The nurse should have worn sterile gloves. B. The temperature of the irrigating solution was incorrect. C. The nurse disconnected the drainage tubing from the catheter. D. The rate at which the irrigating solution was instilled was incorrect. E. The nurse performed closed intermittent catheter irrigation correctly.

C. The nurse should not open the urinary catheter system to perform closed intermittent catheter irrigation. Opening the system places the patient at greater risk for developing a urinary tract infection. The nurse should have clamped the drainage tubing below the soft injection port, cleaned the port with an antiseptic swab, connected the sterile needleless syringe, and instilled the irrigating solution. The nurse would then remove the clamp, allowing the solution to drain into the urinary drainage bag.

A nurse is to perform a bladder scan on a patient to measure PVR. After the patient voids, the nurse measures and documents the volume of voided urine. The nurse returns in 20 minutes and places the patient supine with head slightly elevated, exposing the patient's lower abdomen. The nurse turns on the scanner and sets the gender designation. The nurse applies a generous amount of ultrasound gel above the patient's symphysis pubis, and releases the scan button and then applies the scanner head to the gel, pointing it in a downward direction toward the bladder. The nurse wipes the abdomen of the gel and documents the procedure. What error(s) occurred in the performance of the skill? (Select all that apply.) A. The order of having the patient void followed by the bladder scan. B. The positioning of the patient. C. The length of time between the patient voiding and performing the bladder scan. D. The timing of pressing and releasing the scan button. E. The amount of ultrasound gel applied. F. Cleaning of the scanner head.

CDF

__________________ is used to perform catheter care, and sterile gloves are unnecessary.

Clean technique

A ________________________ catheter is often used for men with prostatic hypertrophy.

Coude (elbowed/curved)

The nursing assistive personnel (NAP) reports the patient who is 1 day postoperative from bladder surgery is complaining of lower abdominal pain. The nurse palpates the patient's bladder and finds it is distended and there has not been any change in the amount of urine in the last 2 hours in the drainage bag. The patient's vital signs are within normal limits. What is the nurse's best action? Encourage the patient to drink more fluids and request an order to increase the patient's rate of intravenous (IV) fluids. Note if the urine is cloudy or has a foul odor, obtain a sterile urine specimen, and request an order for a urinalysis. Provide the patient with pain medication, and inform him this is a normal finding during the early postoperative period. Ensure there are no kinks in drainage tubing, and if none, notify health care provider for possible bladder irrigation order.

Ensure there are no kinks in drainage tubing, and if none, notify health care provider for possible bladder irrigation order.

The nurse is to determine PVR on a patient who has been experiencing incontinence, but a bladder scanner is unavailable. What is the nurse's best action? A. Have the patient void and measure the amount; have the patient void again and measure the volume within 5 to 15 minutes of the first voiding. B. Notify the health care provider. C. Document hourly outputs using a urinometer. D. Have the patient void and measure the volume, then perform straight catheterization. E. If a bladder scanner is not available, obtain a PVR by measuring urine emptied from the bladder after a straight catheterization.

Have the patient void and measure the volume, then perform straight catheterization.

Which of the following would be inappropriate to delegate to NAP? Application of a condom catheter. Perineal care. Emptying a leg bag and recording on I&O record. Indwelling catheter insertion.

Indwelling catheter insertion.

Which of the following requires strict surgical asepsis? Applying a condom catheter Performing catheter care Insertion of an indwelling catheter Emptying a bedside drainage bag

Insertion of an indwelling catheter Inserting a Indwelling catheter is an invasive procedure requiring aseptic technique.

_________________________________ are used in special circumstances such as after urologic surgery or in cases of gross hematuria.

Larger size catheters (20-22 Fr)

The nurse is assessing the patient's condom catheter. Which of the following most likely indicates the condom catheter should be removed? Patient complains of the leg bag feeling "heavy" while in bed. Redness and/or excoriation of the penis Patient's urine appears clear amber with ammonia smell. Less than 30 mL/hr of urinary output.

Redness and/or excoriation of the penis

_________________________ is used whether inserting a straight or indwelling urinary catheter.

Sterile technique

During change-of-shift report the nurse states that a patient has early renal failure and to be alert to this when administering medications. Why would this be a concern? The kidneys assist in the detoxification of medication metabolites. The patient may not be able to absorb all of the medications. The bladder acts as a filter to remove wastes and form urine. The kidneys are the primary site for medication metabolism.

The kidneys assist in the detoxification of medication metabolites. The kidneys detoxify and eliminate by products of medication metabolism. If the kidneys are unable to perform this function, medication toxicity can develop. The nephron, the functional unit of the kidney, forms the urine. The bladder holds the urine until it is excreted. The liver is a primary site for medication metabolism.

Which of the following indicates a reason for notifying the health care provider to get an order for removal of an indwelling catheter? The patient states, "My bladder feels so full, it is starting to hurt!" The catheter has been in place for 3 days. The patient's urine appears cloudy with a foul odor. The patient is drinking less than 1500 mL of fluids daily.

The patient's urine appears cloudy with a foul odor.

A health care provider has ordered an indwelling catheter to be inserted for bedside drainage. Which of the following is NOT an expected indication for catheterization with an indwelling catheter? Preoperative status. To determine urinary retention. To obtain accurate urinary output in a critically ill patient. To allow a pressure ulcer on the coccyx to heal in a patient with urinary incontinence.

To determine urinary retention. A straight catheter or bladder scan may be used to determine urinary retention and would not be an indication for an indwelling catheter. Indications for an indwelling catheter include preparing for surgery, to obtain accurate output measurements, and for incontinent patients in whom a wound needs to heal.

A 14 to 16 Fr catheter 5-mL balloon is indicated for ______________; the smaller size catheter should be chosen first to prevent urethral trauma.

adults

The bedside drainage bag should be ________________________ and not the bed rails to avoid accidentally raising the rails (and the collection bag) above the level of the bladder, allowing reflux of urine.

attached to the bed frame

After reviewing the signs of infection, characteristics of normal urine, and the proper procedure, this task can be ______________________________________

delegated to NAP and/or family members.

If the catheter was in place for more than several days, the patient may experience ________________________ resulting from inflammation of the urethral canal.

dysuria (painful voiding)

8 to 10 Fr with 3-mL balloon is generally used with ____________________.

children

Patients may use ___________________________ in the home setting for intermittent catheterization.

clean insertion technique

The nurse is assisting the NAP to remove an indwelling catheter. The nurse should intervene if which of the following actions is noted? The NAP: connects an empty syringe to the balloon port and allows it to fill passively. cleans the patient's perineal area, hands the patient their call light, and removes gloves. makes sure the balloon is completely deflated before removing the indwelling catheter. explains the procedure to the patient, regardless of condition or level of awareness.

cleans the patient's perineal area, hands the patient their call light, and removes gloves. To prevent the transmission of microorganisms the NAP should remove the used gloves and perform hand hygiene before handing the patient any personal items or the call light. The patient should receive a thorough explanation of the catheter procedure, regardless of condition or level of awareness. The syringe should be allowed to fill by gravity. To prevent trauma to the patient's urethra, the balloon should be completely deflated before removal.

Cleansing the far labial fold, the near labial fold, and directly over the center of urethral meatus using a new swab with each area is the ________________ procedure for cleaning the female patient.

correct

If there is resistance to catheter insertion, the nurse should________________________________________ to promote relaxation while inserting the catheter slowly.

have the patient take slow deep breaths

The NAP documents "Peri-care given" next to "Urinary Catheter" on a patient with an indwelling urinary catheter. What is the best explanation of what the NAP did after application of clean gloves? The NAP: washed the perineal area with soap and water and applied a topical antimicrobial ointment at the urethral meatus around the catheter. stabilized the catheter and washed the catheter with soap and water from where the catheter enters the meatus down 4 inches toward the drainage tubing. inserted the hub of syringe into balloon port allowing the sterile water to return passively into the syringe and slid the catheter out into a waterproof pad. obtained a squirt bottle of warm water and had the patient squirt it over their perineum while sitting on the toilet.

stabilized the catheter and washed the catheter with soap and water from where the catheter enters the meatus down 4 inches toward the drainage tubing.

The urinary tract is ____________.

sterile

When the patient is in an acute care or long-term care setting, _______________________________ technique is required because of the high risk for nosocomial infections.

sterile insertion

If resistance occurs when inflating balloon or the patient verbalizes or shows nonverbal signs of pain...

the balloon may not be entirely within the bladder Stop inflation; allow fluid to flow back into syringe, and advance the catheter a little more before reattempting to inflate.

If there is persistent resistance to insertion...

the patient may have an enlarged prostate. Then it is appropriate to notify the health care provider; a Coudé catheter, with a slightly curved end, may be needed to facilitate insertion.

If there is resistance to catheter insertion, another technique is...

to rest the nurse's arm against the patient's leg and ask him to relax. When the leg muscles begin to relax, the nurse may continue the insertion process.

The bedside drainage bag should be emptied when __________ full, or at least once every ______ hours.

two-thirds; 8