Elimination Practice Test
The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When would the nurse inflate the balloon? Insert the catheter until resistance is met and inflate the balloon. Advance the catheter to the bifurcation and inflate the balloon. Insert the catheter 2.5 cm to 5 cm and inflate the balloon. Immediately inflate the balloon.
Urinary catheterization is a sterile procedure. When inserting an indwelling catheter, the nurse should ensure the balloon is in the bladder before inflating it. If the balloon is inflated in the urethra of the male client, trauma may occur. When catheterizing a male client, the nurse observes the tubing for the flow of urine, continues to advance the catheter to the point of bifurcation, and then inflates the balloon. The nurse then pulls the catheter back until slight resistance is felt and applies a tube holder onto the thigh to hold the catheter in place. The balloon should not be inflated when urine is first observed, after advancing several more centimeters, or when resistance is felt.
The staff nurse is observing a new graduate nurse provide indwelling urinary catheter care to an uncircumsized male client. Which action by the new graduate nurse would indicate a need for further teaching? Removes a loose catheter anchor and places a new anchor on the shin Uses the nondominant hand to pull back the foreskin to cleanse the urethral meatus with soap and water and returns the foreskin to its normal position Maintains the urinary collection bag below the level of the bladder Cleans the catheter proximally to distally with soap and water
Routine catheter care is imperative in the prevention of catheter-associated urinary tract infections (CAUTIs). Meticulous technique needs to be used to prevent the introduction of microorganisms to the urinary tract. For uncircumcised males, the nurse would retract the foreskin to inspect the urethral meatus for skin irritation and then cleanse the site with warm soapy water and return the foreskin to its normal position. The catheter tubing needs to be cleaned in a proximal to distal direction. The urinary drainage bag needs to be maintained below the level of the bladder to prevent reflux of urine into the urinary tract. Any loose anchors need to be removed and replaced to ensure the catheter tubing does not get pulled on, as this could cause trauma to the urethra. However, the anchor needs to be placed on the upper thigh, not the shin. Therefore, option 3 is the action that requires a need for further teaching.
The nurse is inserting an indwelling urinary catheter in a client and begins to inflate the balloon when the client starts complaining of pain. Which action would the nurse take? Deflate the balloon, slightly withdraw the catheter and attempt to reinflate the balloon Stop inflating the balloon, allow the saline solution to drain into the syringe and advance the catheter further before reinflating the balloon Continue to inflate the balloon Deflate the balloon, completely withdraw the catheter and end the procedure to notify the primary health care provider
The client's pain during inflation of the balloon may be related to the urinary catheter tip being located in the urethra and not the bladder. If the client begins to complain of pain with the inflation of an indwelling urinary catheter balloon, the nurse would allow the fluid injected into the balloon to drain back into the syringe attached to the balloon inflation port. Then, the nurse would advance the catheter further into the urethra to the bladder and then attempt to inflate the balloon. Therefore, option 4 is correct.
A client with a neurological impairment experiences urinary incontinence. Which nursing action would help the client adapt to this alteration? Padding the bed with an absorbent cotton pad Establishing a toileting schedule Inserting an indwelling urinary catheter Using adult diapers
A bladder retraining program, such as use of a toileting schedule, may be helpful to clients experiencing urinary incontinence. An indwelling urinary catheter should be used only when necessary because of risk of infection. Use of diapers or pads is the least acceptable alternative because the risk of skin breakdown exists.
The nurse evaluates that there is a need for further teaching on bowel elimination when the client makes which statement? "I walk 1 to 2 miles per day." "I drink 6 to 8 glasses of water per day." "I need to decrease fiber in my diet." "I have a bowel movement every other day."
Adequate dietary fiber is an important factor for improving bowel function. Dietary fiber increases fecal weight and water content and accelerates the transit of the fecal mass through the gastrointestinal (GI) tract. The retention of water by the fiber has the ability to soften stools and promote regularity. Fluid intake and exercise also facilitate bowel elimination.
A primary health care provider has ordered digital removal of stool for a constipated client. How would the nurse position the client for this procedure? Right lateral Sims' position Prone position Lithotomy position Left lateral Sims' position
For digital removal of stool, the client would be placed in the left lateral Sims' position, as this follows the anatomical curvature of the colon. Options 1, 2 and 4 are not appropriate positions for this procedure.
The nurse is told by an older woman that she has begun to be incontinent of urine at night and now drinks no fluids after 6.00 pm. Which is the nurse's best response? "Older people do not need as much fluid intake as younger people." "Incontinence is to be expected in old age." "Incontinence at any age should be evaluated by your primary health care provider." "That's a good idea; you're the best judge of how much fluid you should or should not drink."
Urinary incontinence requires evaluation as to the cause so that appropriate treatment can begin. Incontinence is not expected in old age, and the statement about expecting incontinence represents stereotypical thinking. It is not correct to say that older adults do not need as much fluid intake as younger adults. This is also stereotypical thinking. The idea that most adults are able to judge fluid needs may be true generally but may not apply because of the development of this new problem.
The nurse is reinforcing instructions to a client about the types of fluids that assist in prevention and treatment of urinary tract infections (UTIs). The nurse instructs the client to consume which fluids? Select all that apply. Cranberry juice Soda Apple juice Prune juice Milk
The client at risk for UTIs should be instructed to consume adequate amounts (2000 to 2500 mL/day) of fluids. Certain fluids such as prune juice, apple juice, cranberry juice, and water can be used to minimize the risk for development of UTI. Dairy products and carbonated beverages should be avoided because they are alkylating agents.
The surgeon asks the nurse to obtain a urinary catheter that will be used for continuous bladder irrigation. Which urinary catheter would be the nurse obtain? A double-lumen catheter A straight catheter A Coudé tip catheter A triple-lumen catheter
Straight catheters are used for intermittent catheterization. Double-lumen catheters are used for indwelling urinary catheterization in which one lumen drains urine in the bladder and the other lumen is used to inflate and deflate the balloon. Triple-lumen catheters are used for continuous bladder irrigation or bladder medication instillation. One lumen is to inflate and deflate the balloon, another lumen is to drain urine and the irrigation solution, and the other lumen instills the irrigation solution into the bladder. A Coudé tip catheter is a catheter with a curved tip at the end used to advance the catheter past a hypertrophied prostate, in which using a standard catheter would be difficult. Therefore, option 3 is correct.
A client has a urinary tract infection (UTI). The nurse is giving the client instructions to prevent recurrence. The nurse determines that the client needs further teaching if the client states the intention to do which action? Continue to take antibiotics until all symptoms are gone. Limit the force of the stream during voiding. Drink an increased amount of fluids. Use condoms to eliminate risk associated with chlamydia and gonorrhea.
The client who experiences epididymitis from UTI should increase intake of fluids to flush the urinary system. Because organisms can be forced into the vas deferens and epididymis from strain or pressure during voiding, the client should limit the force of the stream. Condom use can help prevent urethritis and epididymitis from STIs. Antibiotics are always taken until the full course of therapy is completed.
