Module 14: Urinary Catheters

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.

a) Place the catheter bag lower than the client and assess for the flow of urine.

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

a) attached to the bed itself lower than the client

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

a) to the catheter bifurcation

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

a) Insert a syringe into the balloon inflation port and allow the water to come back by gravity.

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.

a) Irrigate the catheter with normal saline to restore patency.

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.

a) Leave the misplaced catheter in place as a marker and repeat the procedure with a new catheter.

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) A client post bladder surgery.

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.

a) Advance the catheter an additional 2 to 3 in (5 to 7.5 cm).

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.

a) Check the catheter tubing for kinks or twisting.

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.

a) Clamp or fold the catheter tubing below 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.

a) Compare it to the client identification band.

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.

a) Do not force the catheter.

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.

a) Opening the catheter can lead to contamination and infection.

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."

b) "Take several slow, deep breaths."

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.

b) An antimicrobial swab.

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

b) Bend the drainage tubing back on itself distal to the port.

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 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.

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.

b) Deflate the balloon, remove the catheter, and replace.

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.

b) Empty the urine from the syringe into a specimen cup with a lid.

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.

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.

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.

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

b) Nonsterile gloves

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.

b) Notify the client's health care provider.

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.

b) On the client's left side, if left handed.

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.

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

b) Remove the current catheter and reinsert a new one.

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

b) Replace the foreskin into its non-retracted position.

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.

b) Stop for a moment and have the client take several slow, deep breaths.

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.

b) The port.

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.

b) Unclamp the drainage tubing.

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.

b) Using a circular motion, move from the meatus down the glans of the penis.

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.

b) With an alcohol wipe.

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."

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

c) 10 mL

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

c) 2 to 3 in (5 to 7.5 cm) from the tip of the catheter

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

c) Up to 30 minutes.

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?"

d) "Do you have a history of prostate problems?"

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."

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.

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.

d) Place it on the waterproof pad and wrap it in the pad.

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.

d) Reattach the syringe to the port, aspirate again, and reattempt catheter removal.

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.

d) Stop the procedure, obtain new supplies, and restart procedure.

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.

d) Wipe from above urinary orifice downward toward sacrum.

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

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

d) on the client's right side