Question 1

Prior to applying the condom catheter,which action by the nurse is the most appropriate?

Accepted Answer

Before applying the condom catheter, the nurse should inspect and cleanse the penis to prevent infection and ensure proper adhesion of the condom catheter. Documenting the use of the catheter and attaching the urinary drainage system securely are important steps, but should only be done after the penis has been prepared. Calling the healthcare provider is not necessary for this routine procedure.

Question 2

The nurse is caring for a client with an indwelling catheter.When emptying the urine collection bag,the nurse notes the urine is cloudy with moderate amounts of sedimentation and a foul odor.Based on these assessment findings,what does the nurse suspect?

Accepted Answer

Cloudy urine with sediment and foul odor are classic signs of a urinary tract infection. The indwelling catheter provides a direct route for bacteria to colonize and cause infection. Further assessments such as obtaining a urine culture and sensitivity may be necessary.

Question 3

When is it appropriate for the nurse to prepare a new ostomy pouch for a client?

Accepted Answer

Preparing a new ostomy pouch before removing the old one whenever possible helps to prevent the client from being exposed to the fecal matter or other contents in the old pouch. This can also help to minimize the risk of skin irritation or infection. However, there may be situations where the old pouch needs to be removed first, such as in cases of a leaking or damaged pouch.

Question 4

The nurse is caring for a client with a newly created urinary diversion ostomy appliance.Which is the priority when caring for this client?

Accepted Answer

Teaching the client self-care and support persons' care is the priority as this will promote independence and prevent complications associated with the ostomy. Increasing or limiting fluid intake may be necessary based on the individual client's needs, and administering IV fluids may not be necessary if the client is able to tolerate oral intake. However, education on self-care and support-person care is essential for long-term management of the ostomy.

Question 5

The nurse is caring for an older adult male client who demonstrates frequent urinary incontinence.Which option could the nurse use to reduce the risk of skin damage secondary to urinary incontinence for this client?

Accepted Answer

A condom catheter is a non-invasive option for male urinary incontinence that can help reduce the risk of skin damage. It is a sheath-like device that is placed over the penis and attached to a drainage bag, allowing urine to be collected without contacting the skin. The other options (Robinson catheter, straight catheter, and Foley catheter) are all invasive and involve inserting a tube into the bladder, which can increase the risk of infection and cause further damage to the delicate skin in the perineal area.

Question 6

The nurse is caring for a client with a prescription to discontinue the indwelling urinary catheter that has been in place for 2 weeks.Prior to removing the catheter,which action by the nurse is the most appropriate?

Accepted Answer

Clamping the catheter for increasing periods to retrain the bladder to hold increasing amounts of urine before emptying is the most appropriate action by the nurse. This helps the bladder to regain its function and reduces the risk of urinary retention after catheter removal. Collecting urine for culture and sensitivity is important, but can be done after catheter removal. Cleansing the urethral meatus and preparing a straight catheter are also important, but are not the most appropriate actions prior to removing the indwelling catheter.

Question 7

Which term is not used interchangeably with urinary elimination?

Accepted Answer

Incontinence refers to the lack of control over urinary elimination, while the other terms (micturition, voiding, and urination) are used interchangeably to refer to the act of emptying the bladder.

Question 8

When collecting a urinary elimination history,which item is not appropriate for the nurse to )during this process?

Accepted Answer

History of erectile dysfunction is not relevant to urinary elimination and therefore not appropriate to ask during this process. The other options are all important in assessing a patient's urinary elimination history.

Question 9

The nurse is caring for an older adult client with a medical diagnosis of benign prostatic hyperplasia resulting in urinary retention.When attempting to pass the catheter,the nurse encounters an obstruction,and cannot get the catheter to pass beyond it.Which action by the nurse is the most appropriate?

Accepted Answer

Attempting to pass a Coudé catheter may be appropriate in cases of urinary retention with an obstructed urethra. This type of catheter is specifically designed with a curved tip to navigate past obstructions. Documenting and notifying the health care provider is also important, but attempting to use a Coudé catheter should be the initial action. Pushing the catheter past the obstruction or applying ice to the penis are not appropriate interventions and could cause harm.

Question 10

After applying a condom catheter,which items will the nurse include in the documentation?

Accepted Answer

When documenting the application of a condom catheter, the nurse should include the appearance of the penis, such as swelling or discoloration, the amount of urine flow, any client complaints or concerns, and the time of application. While assessment 30 minutes after application and every 8 hours thereafter is important to monitor for any complications or skin breakdown, it is not typically included in the documentation of the initial application of the condom catheter.

Question 11

The nurse is preparing to insert a urinary catheter.Place the steps for this procedure in the proper order.

Accepted Answer

First, the nurse should apply sterile gloves (B) and organize the supplies in the catheter kit (D). Then, a sterile drape should be placed under the patient's buttocks or penis without contaminating the center (E). Next, the meatus should be cleansed (A) before inserting the catheter. Finally, if recommended by the manufacturer, the balloon of the indwelling catheter should be tested (C).

Question 12

The nurse is caring for a client receiving continuous bladder irrigation following transurethral prostatectomy.When emptying the urine collection bag,the nurse notes that 500 mL of irrigant has infused with only 100 mL of drainage returned.Which is the priority action by the nurse?

Accepted Answer

The priority action is to ensure patency of the catheter by irrigating the outflow port, as the low drainage could indicate a blockage.

Question 13

The nurse is caring for a client who requires long-term catheterization who is allergic to latex.Which catheter would the nurse choose to insert?

Accepted Answer

The best choice for a client who is allergic to latex is a silicone catheter as it is latex-free and offers a more biocompatible option for long-term catheterization. PVC and plastic catheters may contain latex, and a latex catheter would obviously be contraindicated in this situation.

Question 14

Which task could the nurse safely delegate to the unlicensed assistive personnel (UAP)?

Accepted Answer

Applying a condom catheter is a task that can be safely delegated to unlicensed assistive personnel (UAP) as it does not require the sterile technique or invasive procedures that are necessary for inserting urinary catheters or collecting detailed patient histories, which are tasks that should be performed by licensed nursing staff.

Question 15

After emptying the urine from a urinal,which actions by the nurse are appropriate?

Accepted Answer

These actions are appropriate because they help to maintain the client's hygiene and comfort, and they provide accurate documentation of the client's fluid output.

Question 16

The nurse is initiating closed continuous bladder irrigation using a three-way catheter.Prior to beginning the flow of the irrigation fluid,which action by the nurse is the most appropriate?

Accepted Answer

The answer of The nurse is initiating closed continuous bladder...

Question 17

When performing catheter care,which action is not appropriate for the nurse to perform?

Accepted Answer

Applying sterile gloves is not appropriate for routine catheter care. Standard precautions, including the use of clean gloves, are sufficient for this procedure. Sterile gloves are generally reserved for procedures that require a sterile field.

Quiz 20: Assisting With Urinary Elimination