Urinary Elimination
Which action will the nurse implement to reduce the risk of catheter-associated urinary tract infection (CAUTI) in a male patient with an indwelling urinary catheter? Frequently pull on the drainage system tubing. Use the largest-size catheter possible. Clean the urinary meatus daily. Apply antiseptics to the urinary meatus.
Clean the urinary meatus daily. Apply antiseptics to the urinary meatus. CORRECT. To reduce the risk of CAUTI, daily cleansing of the urinary meatus is necessary.
Which statement might the nurse make to nursing assistive personnel (NAP) before delegating the collection of a routine urine sample from a patient with an indwelling urinary catheter? "Does the patient understand why the specimen is needed and why we cannot obtain it from the Foley bag?" "See if the catheter is causing the patient any problems and if he is having any pain." "Please get two sterile urine collection containers from the utility room." "Let me know if the urine contains blood or sediment, or appears cloudy."
"Let me know if the urine contains blood or sediment, or appears cloudy." CORRECT. This statement correctly focuses on the characteristics of urine that an NAP must report to the nurse.
Which action will ensure that a sterile urine specimen is handled properly in order to help obtain reliable results? Placing the specimen in a biohazard bag Having someone take the specimen to the lab immediately Cleaning the outside surface of the container Ensuring that a stock of sterile urine collection kits is available
Having someone take the specimen to the lab immediately CORRECT. Having someone take the specimen to the lab immediately will help to ensure reliable results. The specimen must be delivered to the lab within 20 minutes of collection.
While performing an intermittent straight urinary catheterization of a female patient, the nurse inadvertently inserts the catheter into the patient's vagina. Which action would the nurse take next? Remove the catheter, and rinse it thoroughly in sterile water for reuse. Keep the catheter in place, and begin again with a new sterile catheter. Remove the catheter, relubricate it, and insert it into the urinary meatus. Stop advancing the catheter, and notify the health care provider.
Keep the catheter in place, and begin again with a new sterile catheter. CORRECT. This action is correct. If a straight catheter is inadvertently inserted into the vagina, it should be left in place as a landmark, and the nurse must begin the catheterization process again with a new sterile catheter
3. Which instruction might the nurse give to nursing assistive personnel (NAP) helping to care for a patient receiving bladder irrigation? "Tell me how he tolerates the irrigation." "Be sure to check for signs of a urinary tract infection." "Measure and report the patient's temperature to me every 4 hours." "Ask the patient about pain level."
"Measure and report the patient's temperature to me every 4 hours." CORRECT. This is the correct answer. Measuring and reporting temperature is a skill that may be delegated to NAP
During intermittent open bladder irrigation, a patient complains of pain. Which action would the nurse take first? Examine the drainage tubing for clots, sediment, and kinks. Notify the health care provider. Leave the irrigation drip wide open. Monitor the patient's vital signs.
Examine the drainage tubing for clots, sediment, and kinks. CORRECT. This is the correct answer. If the patient complained of pain during intermittent open bladder irrigation, the nurse would first examine the drainage tubing for clots, sediment, and kinks.
Which is not an expected outcome on a first voiding after catheter removal? Mild burning Fever and back pain Producing only a small amount of urine Discomfort
Fever and back pain CORRECT. The nurse would instruct the patient to report signs of a urinary tract infection, such as fever and back pain. These signs are unlikely to be present during the patient's first voiding after catheter removal.
which action would the nurse take to manage continuous urinary catheter irrigation for a patient whose urine is bright red and contains clots? Increase the irrigation drip rate. Notify the patient's health care provider of the blood and clots in the urine. Encourage the patient to increase fluid intake. Apply ice to the patient's lower abdominal area. CORRECT. This is the correct answer. The nurse wo
Increase the irrigation drip rate. CORRECT. This is the correct answer. The nurse would increase the irrigation drip rate to flush the urinary tract until the urine was only tinged pink with blood.
What is the best reason for the nurse to instruct a male patient to take slow, deep breaths during insertion of an indwelling urinary catheter? To increase oxygenation To reduce blood pressure To distract him To promote relaxation
To promote relaxation CORRECT. The nurse would instruct a male patient to take slow, deep breaths during catheter insertion if the nurse felt resistance to the advancing catheter or if the patient reported pain. Deep breathing promotes relaxation, which might help to pass the catheter through the urinary sphincter.
Which statement best illustrates the nurse's understanding of the role of nursing assistive personnel (NAP) when inserting an indwelling urinary catheter in a female patient? "Please direct the light to better illuminate the patient's perineal area." "You need to be comfortable inserting a catheter in a patient of her size." "See if a size 14-French catheter is big enough." "Find out if the patient has any allergies to latex or iodine."
"Please direct the light to better illuminate the patient's perineal area." CORRECT. This is the correct answer. No aspect of the skill of indwelling urinary catheter insertion may be delegated to NAP, but the nurse may delegate related tasks, such as redirecting the lighting during the procedure.
Which statement might the nurse make to nursing assistive personnel (NAP) assigned to care for a patient with an established suprapubic catheter? "Tell me if the catheter site looks inflamed." "I need to know the patient's temperature each time it's taken." "Wear sterile treatment gloves when you remove the dressing." "Let me know if the patient's catheter is infected"
"I need to know the patient's temperature each time it's taken." CORRECT. Temperature measurement can be delegated to NAP. This statement is appropriate for the nurse to make.
The nurse instructs nursing assistive personnel (NAP) regarding proper technique for intermittent straight catheterization of a male patient. Which statement made by NAP indicates that the instruction was effective? "I'll help you set up the sterile field." "I'll get a sterile urine cup for you." "There are leg straps in the utility room." "I'll help keep his legs away from the sterile field."
"I'll help keep his legs away from the sterile field." CORRECT. NAP can assist with intermittent straight catheterization by helping with patient positioning and comfort
Which statement might the nurse make to nursing assistive personnel (NAP) caring for a patient who has just had an indwelling urinary catheter removed? "Teach the patient the signs of a urinary tract infection." "Tell me when and how much the patient first voids." "Explain that voiding might be uncomfortable for 4 to 5 days." "Assess the patient for a distended bladder before the end of the shift."
"Tell me when and how much the patient first voids." CORRECT. The nurse may delegate to NAP the task of reporting the time and amount of the patient's first voiding after removal of an indwelling urinary catheter.
Which action(s) would minimize the patient's risk for injury during insertion of an indwelling urinary catheter? Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based substances Thoroughly cleansing the patient's perineal area with povidone-iodine solution before inserting the catheter Performing proper hand hygiene and applying gloves before inserting the catheter Terminating the insertion if the patient reports pain at any time during the procedure
Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based substances CORRECT. This is the correct answer. Serious allergic reactions may occur if the patient has an allergy to latex, antiseptic, tape, or iodine-based cleanse
Which nursing action minimizes a patient's risk for injury during removal of an indwelling urinary catheter? Using a 5-mL syringe to deflate the balloon Using sterile scissors to cut the valve to deflate the balloon Tugging gently on the catheter to pull the balloon through the urethra Checking the documentation for the volume of fluid used to inflate the balloon
Checking the documentation for the volume of fluid used to inflate the balloon CORRECT. Checking the volume of fluid used to inflate the balloon in order to ensure the balloon is completely deflated before removal is the nursing action that will minimize a patient's risk for injury during removal of an indwelling urinary catheter.
When collecting a urine specimen from an indwelling urinary catheter, which action is most likely to ensure that sufficient urine is collected? Checking the patency of the indwelling catheter tubing Placing the urinary collection bag below the level of the bladder Clamping the catheter tubing for 15 minutes before collection Asking the patient to drink a glass of water 30 minutes before the collection
Clamping the catheter tubing for 15 minutes before collection CORRECT. Clamping the catheter tubing for 15 minutes before collection will ensure that sufficient urine is available for the specimen.
Which action is most important in reducing the risk for infection in a patient receiving open intermittent irrigation of a urinary catheter? Attaching the urinary drainage bag to the bed frame Inspecting the drainage tubing for kinks Disposing of contaminated items after the procedure Cleaning the end of the drainage tubing with an antiseptic wipe before reconnecting it to the catheter
Cleaning the end of the drainage tubing with an antiseptic wipe before reconnecting it to the catheter CORRECT. This is the correct answer. Swabbing the end of the drainage tubing with an antiseptic wipe before reconnecting it to the catheter reduces the number of pathogens that migrate from the tubing directly into the bladder.
While attempting to perform a straight catheterization for a male patient, the nurse advances the catheter 3 to 4 inches into the meatus but observes no urine flow. Which action would the nurse take at this time? Continue to advance the catheter until 5 to 7 inches of the catheter tube has been introduced into the urethra. Withdraw the catheter to 1 inch, and ask the patient to cough. Encourage the patient to cough as the catheter is advanced. Apply pressure to the patient's lower abdomen over the bladder.
Continue to advance the catheter until 5 to 7 inches of the catheter tube has been introduced into the urethra. CORRECT. This is the correct option, because the urethra may be longer than 3 to 4 inches.
A newly inserted suprapubic catheter becomes dislodged. What action should the nurse perform first? Notify the health care provider Apply pressure over the site Cover the site with a sterile dressing Help the patient into a side-lying position
Cover the site with a sterile dressing CORRECT. When a newly inserted suprapubic catheter becomes dislodged, the nurse's first action is to cover the site with a sterile dressing.
A patient with a suprapubic catheter is complaining of pain. What will the nurse do first to help this patient? Ensure that the patient is not lying on the drainage tubing Instruct the patient to increase his or her oral fluid intake Observe the rate of drainage in the urine collection bag Notify the health care provider
Ensure that the patient is not lying on the drainage tubing CORRECT. The nurse will first ensure that the patient is not lying on the drainage tubing, since doing so could obstruct urine flow and cause pain.
Which measure may be taken to minimize the staff's risk for infection from a urine specimen? Firmly securing the lid of the urine specimen container Using a sterile urine specimen container Using a sterile syringe to access the sampling port Placing the urine specimen container in the refrigerator until the laboratory comes to get it
Firmly securing the lid of the urine specimen container CORRECT. Securing the specimen container lid is one way to minimize the risk for infection to the staff.
When preparing to insert an indwelling urinary catheter in a male patient, it is important for the nurse to do what? Remove the cotton balls from the kit for later use. Advance the catheter 10 to 12 inches or until urine flows. Lubricate the first 5 to 7 inches of the catheter. Hold the penis at a 45-degree angle during insertion.
Lubricate the first 5 to 7 inches of the CORRECT. The first 5 to 7 inches of the catheter is lubricated to ease insertion.
The nurse has completed an intermittent straight urinary catheterization of a female patient. Which action would the nurse delegate to nursing assistive personnel (NAP)? Measure and empty the urine. Palpate the abdomen. Ask the patient if she has any pain. Document the procedure.
Measure and empty the urine. CORRECT. The NAP can measure and empty the urine collection tray after an intermittent straight catheterization.
The nurse has completed the initial inspection of the patient's perineum and is preparing to insert an indwelling urinary catheter. Which action would the nurse complete next? Begin to establish a sterile field. Open and assemble the urine drainage bag. Remove soiled gloves, and perform hand hygiene. Center the drape over the patient's labia.
Remove soiled gloves, and perform hand hygiene. CORRECT. This is the correct answer. The nurse's soiled gloves must be removed prior to setting up the sterile field.
While setting up the sterile field in preparation for inserting an indwelling urinary catheter, a male patient is incontinent of urine over most of the supplies. What action would the nurse take to reduce the patient's risk for infection? Rinse off the supplies that were contaminated with urine. Cleanse the patient's urinary meatus. Replace all contaminated supplies, and begin the process again. Change the patient's bed linens.
Replace all contaminated supplies, and begin the process again. Change the patient's bed linens. CORRECT. If the sterile field is contaminated while preparing to insert an indwelling urinary catheter, all contaminated supplies must be replaced and the process begun again.
A female patient placed in the dorsal recumbent position for the insertion of an indwelling urinary catheter tells the nurse that she "doesn't feel comfortable in this position" and that her "back really hurts." What is the nurse's best response? Reassure the patient that the procedure will take only a few minutes. Promise to reposition the patient as soon as the catheter has been inserted. Reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip. Explain to the patient that the position will allow the catheter insertion to be more efficient.
Reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip. CORRECT. This is the correct answer. The side-lying (Sims') position is an acceptable alternative that may be more comfortable for the patient.
Which nursing action reduces the risk of injury in a patient with a suprapubic catheter? Applying sterile gloves before cleaning the catheter insertion site Cleansing the skin surrounding the insertion site Securing the catheter to the abdomen Keeping the drainage bag above the level of the patient's bladder
Securing the catheter to the abdomen CORRECT. Securing the catheter to the abdomen will reduce the risk of injury to the patient by ensuring that excess tension is not applied to the catheter. Such tension could damage the bladder
Why does the nurse need to keep the urine sterile while obtaining a sample from an indwelling urinary catheter? Sterile technique protects the patient from microorganisms in the urine. Sterile technique protects the nurse from microorganisms in the urine. Sterile technique reduces the amount of pain caused by the procedure. Sterile technique ensures that microorganisms in the specimen are from the urine, and not the result of contamination.
Sterile technique ensures that microorganisms in the specimen are from the urine, and not the result of contamination. CORRECT. The nurse will use sterile technique to obtain a urine specimen from an indwelling urinary catheter to ensure that any microorganisms in the specimen are from the urine, not from the patient's skin, the nurse's hands, or the environment.
Which observation indicates that instruction given to nursing assistive personnel (NAP) in caring for a patient with an indwelling urinary catheter has been effective? The collection bag has been placed on the side rail of the bed. The excess catheter tubing has been coiled beside the patient's inner thigh. The collection bag has been placed on the bed. The collection bag is held above the level of the bladder while ambulating the patient.
The excess catheter tubing has been coiled beside the patient's inner thigh. ambulating the patient. CORRECT. The excess drainage tubing should be coiled next to the patient's inner thigh, to facilitate urine flow.
Which action would best minimize a patient's risk for infection during removal of an indwelling urinary catheter? The nurse or nursing assistive personnel (NAP) removing the catheter must employ clean technique. A registered nurse, not NAP, must remove the catheter. Catheter removal must be executed within 10 minutes of beginning the procedure. Catheter removal must take place within 5 days of catheter insertion.
The nurse or nursing assistive personnel (NAP) removing the catheter must employ clean technique. CORRECT. Using clean technique is the best way to minimize the risk of introducing pathogens to the patient's urinary trac
What is the primary reason the nurse applies sterile gloves rather than clean ones when caring for a patient with a newly inserted suprapubic catheter? To protect the nurse and other patients from pathogens To collect a sterile urine sample To reduce the patient's risk of infection To reduce the patient's risk of injury
To reduce the patient's risk of infection CORRECT. This is the correct answer. When providing care for a newly inserted suprapubic catheter, the nurse wears sterile gloves to reduce the risk of infecting the wound at the catheter insertion site.
Why does the nurse cleanse a female patient's perineum before inserting an intermittent urinary catheter? To encourage the bladder to drain fully To encourage spontaneous voiding To prevent bowel elimination during the procedure To reduce the patient's risk of urinary tract infection
To reduce the patient's risk of urinary tract infection CORRECT. The nurse cleanses a female patient's perineum before inserting an intermittent urinary catheter in order to reduce the patient's risk of infection
When preparing to discharge a patient who had an indwelling urinary catheter removed 24 hours ago, the nurse would offer patient education regarding which common complication? Urinary incontinence Urinary tract infection Adequate oral hydration Kidney stones
Urinary tract infection CORRECT. A urinary tract infection may develop 2 to 3 days after indwelling urinary catheter removal, and the nurse would educate the patient to be alert for signs and symptoms of such an infection.
Which action would the nurse take to minimize a patient's risk for injury during urinary catheter irrigation? Change the tubing every 8 hours. Use slow, even pressure when injecting the irrigating fluid. Adhere to aseptic technique during the irrigation process. Monitor the patient's temperature every 4 hours.
Use slow, even pressure when injecting the irrigating fluid. Adhere to aseptic technique during the irrigation process. Monitor the patient's temperature every 4 hours. CORRECT. This is the correct answer. Using slow, even pressure during the instillation of fluid into the bladder helps avert bladder trauma.
Which action would the nurse take to reduce the risk for a catheter-associated urinary tract infection (CAUTI) in a patient with an indwelling urinary catheter? Wear clean gloves when inserting the catheter. Inflate the balloon on the catheter before using it. Use the smallest-size catheter possible. Empty the urine by disconnecting the catheter from the collection bag.
Use the smallest-size catheter possible. CORRECT. This is the correct answer. To reduce the risk of CAUTI in a patient with an indwelling urinary catheter, the nurse would use the smallest-size catheter possible.
