Question 1

The nurse is preparing to insert an indwelling urinary catheter into a female patient who is having major open heart surgery and will be in the intensive care unit after surgery.Which statement about the purpose of the catheter by the patient best indicates that teaching by the nurse was effective?

Accepted Answer

During acute illness,a patient may require urinary catheterization for close monitoring of urine output or to facilitate bladder emptying when bladder function is compromised.An empty bladder does help prevent bladder infections by decreasing the risk of residual urine; however,a bladder infection is not as immediate a threat to the patient as fluid and electrolyte imbalance.A urinary catheter drains urine from an obstruction,but this is not this patient's problem.The catheter does not prevent urinary infections.

Question 2

The nurse inserts an indwelling urinary catheter into an adult patient who has been unable to void.Which assessment finding would the nurse expect?

Accepted Answer

The nurse expects the catheter to drain more than 30 mL/hr of urine as an indication of adequate urine output because it has been a while since the patient voided.A patient complaint of burning or the development of a fever would be unexpected findings and warrant further assessment.Blood-tinged urine would also be an unexpected finding and warrant further assessment.

Question 3

In which position would the nurse place a female patient when preparing to insert a urinary catheter?

Accepted Answer

The nurse assists the female patient to the dorsal recumbent position for insertion of a urinary catheter because this position exposes the perineum adequately to visualize the urinary meatus and maintain aseptic technique during the procedure.Positioning the patient on her stomach,flat in bed,or sitting upright impairs the nurse's ability to expose the perineum,visualize the urinary meatus,maintain aseptic technique,and drain urine from the bladder.

Question 4

The nurse set up the sterile field and is preparing to cleanse a male patient before inserting a urinary catheter.What step is essential for the nurse to use to facilitate insertion?

Accepted Answer

The nurse uses the nondominant hand to hold the penis at a right angle to the body for cleansing so the dominant hand remains sterile to insert the catheter.The nurse retracts the foreskin during cleansing because the meatus is covered partially by the foreskin; the only method of cleansing the meatus is to retract the foreskin.Cleansing the shaft of the penis is unnecessary.The cotton balls remain on the sterile field until needed by the nurse.

Question 5

Discharge teaching for a male patient with an external urinary catheter would include which of the following instructions?

Accepted Answer

The nurse would instruct the patient to squeeze around the penis gently to firmly secure the adhesive to the penis to prevent leaking.Retracting the foreskin before applying an external catheter and removing the hair at the base of the penis are not indicated.Applying a petroleum-based product impairs the ability of the adhesive to adhere to the skin.

Question 6

The nurse reviews an order for a continuous bladder irrigation after prostate surgery.Which action should the nurse take before starting the bladder irrigation?

Accepted Answer

The nurse first confirms that the patient has a triple-lumen urinary catheter before beginning the irrigation.This type of catheter is usually placed while the patient is in the operating room.The nurse labels the irrigation solution properly according to agency policy for patient safety and to prevent inadvertent intravenous infusion.The nurse changes the irrigation tubing according to agency policy; every 12 hours is excessive and is likely to contribute to an infection.The nurse titrates the irrigation solution to maintain clear urine; the rate usually exceeds 100 mL/hr.

Question 7

The nurse notes that 8 hours after removing the patient's indwelling urinary catheter,the patient has not voided.Which intervention should the nurse try first to facilitate patient voiding?

Accepted Answer

The nurse assesses the patient for a history of voiding difficulties,especially after removal of an indwelling catheter,and asks the patient about successful strategies that facilitated voiding.Patient difficulties often arise from the physical distortion of the urinary meatus and sphincters by the urinary catheter; after the urethra and sphincters return to normal and regional edema improves several hours later,the patient voids.Running water in the bathroom,running warm water over the perineum,and applying gentle pressure to the bladder are suitable techniques to stimulate urination after assessing the patient.

Question 8

The patient reports a sharp stabbing pain when the nurse inflates the balloon during insertion of an indwelling urinary catheter.What should the nurse do in response to the patient report of pain?

Accepted Answer

The nurse deflates the balloon promptly because the balloon inflation precipitated the pain.The balloon is probably still in the urethra.It had not been inserted far enough into the patient.It is unnecessary to remove the catheter.After deflating the balloon,the nurse advances the catheter by 2 inches or more before attempting reinflation.The nurse can reassure the patient that the pain should pass and that pain management is available if the sensation persists.

Question 9

The nurse evaluates the effectiveness of the patient's intermittent urinary catheterization for residual urine.Which of the following requires follow-up nursing intervention?

Accepted Answer

Patient complaints of frequency and urgency are consistent with clinical indicators of a bladder infection,which indicates that the intermittent catheterization has been ineffective.Follow-up nursing interventions include increasing patient fluids to dilute and flush out urinary pathogens and collaborating with the provider for potential alterations to the therapeutic regimen,including urine culture and sensitivity.If the patient passes urine in the bathroom,he or she has enough bladder control to reach the bathroom before urinating,which is consistent with clinical indicators of normal urinary function.Normal urine is clear,yellow,and without strong odors and indicates that intermittent urinary catheterization is effective therapy.A nonpalpable bladder indicates an empty bladder and effective intermittent urinary catheterization.

Question 10

Which technique should the nurse use to cleanse the perineum of a female patient during urinary catheter insertion?

Accepted Answer

The nurse uses the nondominant hand to spread apart the labia and maintain the position until the catheter is in place; once the nurse contaminates the nondominant hand by touching the perineum,he or she cannot use that hand to manipulate sterile equipment.Rinsing the perineum is impractical and not necessary.To prevent infection,the nurse uses the dominant hand to cleanse from the urinary meatus to the rectum in one motion.

Question 11

The nurse is making patient care assignments for the staff.Which elimination activity can the nurse delegate to nursing assistive personnel (NAP)for a patient with an indwelling urinary catheter?

Accepted Answer

The nurse delegates care of an indwelling urinary catheter to the NAP because the NAP is trained to perform this task as part of hygienic care.The nurse catheterizes the patient,irrigates a urinary catheter,and obtains a urine specimen for a culture because each task is a sterile procedure performed by the nurse.

Question 12

The nurse encounters resistance during the insertion of a urinary catheter for a male patient.Which action should the nurse implement first?

Accepted Answer

The nurse holds the urinary catheter against the sphincter until it relaxes when resistance is initially met during catheterization of a male patient.If the resistance is from prostatic hypertrophy,the nurse can use a catheter with a smaller,curved tip based on institution policy and healthcare provider preference.Asking the patient to inhale quickly is counterproductive because it effectively creates a Valsalva maneuver and stiffens the sphincter muscle.To prevent tissue trauma,the nurse never applies force to insert a urinary catheter.Removing the catheter is premature until holding the tip against the sphincter has been tried to relax the muscle.

Question 13

The nurse delegates the application of an external urinary catheter to nursing assistive personnel (NAP),including application of an external urinary catheter.Which aspect of applying the external catheter must the nurse perform?

Accepted Answer

The nurse assesses the penis and scrotum before the NAP begins the procedure to establish baseline data.The nurse performs assessment tasks because assessing requires nursing judgment and planning skills.He or she delegates using adhesive to hold the catheter in place,providing hygiene,and allowing a space between the tip of the penis and the end of the catheter for urine flow because the NAP is trained to perform these elimination tasks.

Question 14

The nurse is changing an external urinary catheter on a male patient.Which observation by the nurse requires additional attention?

Accepted Answer

Regardless of the location,dusky skin is cause for concern because it is a clinical indicator of tissue hypoxia.If the tissue is hypoxic,the perfusion is probably inadequate to meet tissue oxygen demand and increases the risk of skin breakdown.Urinating at least every 4 hours is a desirable outcome.Clear urine is a desirable outcome because it indicates urine that is free of sediment and not infected.The dark yellow color can indicate dehydration.Ability to perform self-care for a urinary catheter depends on the physical abilities and motivation of the patient,but it is generally a desirable outcome.

Question 15

The nurse infused a continuous bladder irrigation solution at 250 mL/hr for 12 hours.The total output amount measured was 3720 mL.What should the nurse record for the patient's urinary output?

Accepted Answer

The nurse determines the patient's urine output by subtracting the total volume of irrigation solution infused from the total urinary catheter output because the nurse infused and drained the irrigation solution.
Urinary drainage = 3720
Total of irrigation fluid = (12 hrs × 250 mL/hr)= 3000
Actual urine output = 720 mL

Question 16

The nurse assesses a patient's suprapubic catheter.Which observation warrants further investigation by the nurse?

Accepted Answer

The nurse expects the suprapubic urinary catheter to drain urine continuously; if the flow decreases or stops,the nurse suspects an obstruction or adherence of the catheter against the bladder wall.Regardless of the cause,the nurse investigates interrupted flow of urine to prevent infection,tissue trauma,and patient discomfort.The nurse expects the suprapubic catheter to stay in the stoma,the urine to be yellow and odorless,and the patient to urinate a small volume from the urethra.

Question 17

A patient is going to have an indwelling catheter for the next few weeks as a result of postoperative complications.Which action does the nurse use to prevent the most common complication of an indwelling urinary catheter?

Accepted Answer

Cleansing the indwelling urinary catheter by using circular motions from the urinary meatus to the collection bag tubing decreases the microorganism count on the catheter and prevents a urinary tract infection.The nurse secures the catheter to the patient's leg to prevent retrograde catheter movement into the bladder,which can introduce potential pathogens into the bladder and increases the risk of a urinary tract infection.The nurse keeps the urinary collection bag below the patient's hips to facilitate drainage and prevent retrograde flow of urine to the bladder.The collection bag is emptied at least every shift to prevent infection by removing a potential source of bladder contamination.

Question 18

The nurse determines that the patient's urinary output from the suprapubic catheter is 150 mL for 8 hours.What does the nurse implement as a follow-up nursing intervention?

Accepted Answer

Before concluding that the patient's urinary output is deficient,the nurse completes the assessment to eliminate inadequate intake and catheter obstruction as the potential causes of the low urine output.The nurse expected at least 240 mL of urine in 8 hours.Coughing and deep breathing are ineffective responses for low urine output.Clamping the catheter is wholly counterproductive.The nurse needs to complete the urinary assessment before determining that a diuretic is suitable therapy for the patient; if a diuretic were proper,the patient would exhibit other clinical indicators of fluid volume overload such as crackles,edema,and jugular venous distention.

Question 19

The nurse assesses the patient's skin around the suprapubic catheter and observes extremely reddened skin.Which is the best nursing intervention to promote skin integrity?

Accepted Answer

The best nursing intervention for reddened skin is to keep the area clean and dry.Reddened skin does not necessarily indicate infection; thus the antiseptic ointment can be contraindicated.The catheter drains into a bag and is not attached directly to the skin.There is no stoma when a patient has a suprapubic catheter.

Question 20

Four hours after applying an external urinary catheter,the nurse observes no urine output in the drainage bag.Which intervention should the nurse implement first?

Accepted Answer

Ask the patient if he or she senses the urge to void because it may indicate a full bladder.The patient can also have urinary retention with an urge to void but no urine output.If the patient states that he has no urge to void,the nurse can scan the bladder to evaluate its contents.Catheter tubing kinks do not affect the flow of urine with an external urinary catheter in the same way they would if an indwelling catheter were used.There could be some wetting of the perineum with leakage if the catheter tubing is kinked.The nurse would not notify the healthcare provider until performing patient assessment.Increasing the patient's intake can be contraindicated but can be effective to increase urine output.

Quiz 18: Urinary Elimination