Evolve - Urination

The nursing assistive personnel (NAP) reports leakage around a patient's urinary catheter. What action should the nurse take first? A. Attempt to reinflate the balloon. B. Increase the patient's fluid intake and reassess in 1 hour. C. Remove the catheter and replace with a smaller size. D. Obtain a urine specimen.

A. Attempt to reinflate the balloon.

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.

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

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 close 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 onto 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.

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 close as the nurse attempts to obtain a clear view of the urethra.

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

Advance catheter another 1 to 2 inches and inflate balloon

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? A. 8 French, 3-mL balloon B. 14 French, 5-mL balloon C. 16 French, 5-mL balloon D. 16 French, 30-mL balloon

C. 16 French, 5-mL balloon

The nursing assistive personnel (NAP) is assisting the nurse to insert a Foley catheter on a male patient. In which position should the NAP place the patient? A. Sim's position B. Dorsal recumbent C. Supine with legs adducted D. Supine with legs slightly abducted

D. Supine with legs slightly abducted

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'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, 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.

It is important to anchor the catheter tubing to minimize the risk for urethral trauma, bladder spasms from traction, and to prevent accidental dislodgment.

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 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 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.

Leave the catheter in vagina as a landmark and insert another sterile catheter.

The nurse is catheterizing a male 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? A. Allow fluid to flow back into syringe, and advance the catheter a little more before attempting to re-inflate. B. Have the patient take slow deep breaths inhaling through the nose and exhaling through the mouth. C. Lift penis to position perpendicular to patient's body, and apply light traction. D. Advance catheter to bifurcation of the drainage and balloon inflation port.

A. Allow fluid to flow back into syringe, and advance the catheter a little more before attempting to re-inflate.

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? A. Ask the patient to take slow deep breaths while inserting the catheter slowly. B. Withdraw the catheter and notify the health care provider. C. Apply more force to insert the catheter inward. D. Remove the catheter, apply more lubricant, and reinsert.

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

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. Clean cotton balls F. Sterile forceps G. Sterile water in a syringe (without needle)

A. Sterile cotton balls B. Antiseptic solution D. Water-soluble lubricant F. Sterile forceps

Identify the reasons why a patient with an indwelling catheter may have less than 30 mL per hour of urine in the collection bag: (Select all that apply.) A. The catheter has slipped out of the bladder. B. The patient is severely dehydrated. C. The patient's kidneys are damaged or injured. D. The patient has a UTI.

A. The catheter has slipped out of the bladder. B. The patient is severely dehydrated. C. The patient's kidneys are damaged or injured.

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

B. Above the symphysis pubis

The nurse has been called to make a home visit to a patient with a history of a spinal cord injury and an indwelling Foley catheter. The patient appears diaphoretic and his face is flushed. The nurse takes the patient's vital signs with the following results: Temperature 98.4°F, pulse 54, respirations 20 and blood pressure 160/100. The patient's head of the bed is elevated. What action should the nurse take next? A. Notify the health care provider. B. Check for any kinks in catheter tubing. C. Have the patient take slow deep breaths. D. Lower the head of the bed.

B. Check for any kinks in catheter tubing

Which of the following actions associated with Foley catheterization could cause a potential problem? A. The bedside drainage bag is attached 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 prior to 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. Keeping the foreskin retracted after catheterization.