Question 1

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

Accepted Answer

A dusky color of the skin under the catheter may indicate compromised blood flow or tissue damage, requiring immediate attention.

Question 2

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

Accepted Answer

The dorsal recumbent position, where the patient lies on their back with knees bent and feet flat, provides optimal access to the urethral area for catheter insertion.

Question 3

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

The nurse should assess the patient's intake and catheter patency to determine if the low output is due to decreased fluid intake or a blockage in the catheter.

Question 4

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

Accepted Answer

The nurse should deflate the balloon immediately because the pain indicates that the balloon is being inflated in the urethra rather than the bladder. This can cause injury and should be corrected by advancing the catheter further into the bladder before reinflating the balloon.

Question 5

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

Accepted Answer

The answer of Four hours after applying an external urinary...

Question 6

The nurse notes that 8 hours after removing the patient's indwelling urinary catheter, the patient has not voided.Which action would the nurse take first?

Accepted Answer

Asking about voiding difficulties in the past can help identify any underlying issues that may be contributing to the patient's inability to void.

Question 7

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 must assess the condition of the penis and scrotum before the procedure to ensure there are no contraindications or issues that need to be addressed before applying the catheter.

Question 8

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

Providing catheter care is a non-invasive task that can be delegated to nursing assistive personnel (NAP) as it involves routine hygiene and maintenance of the catheter.

Question 9

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

Accepted Answer

A triple-lumen urinary catheter is necessary for continuous bladder irrigation to allow for simultaneous irrigation, drainage, and balloon inflation.

Question 10

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

Keeping the suprapubic insertion site dry helps prevent skin breakdown and irritation, promoting skin integrity.

Question 11

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

The patient reporting frequency and urgency may indicate incomplete bladder emptying or a urinary tract infection, requiring further assessment and intervention.

Question 12

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

Accepted Answer

The answer of The nurse infused a continuous bladder irrigation...

Question 13

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

The catheter is used to closely monitor urine output, which is crucial for assessing kidney function and fluid balance after major surgery.

Question 14

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 expected outcome after inserting an indwelling urinary catheter is that the urine output should exceed 30 mL in the first hour, indicating that the bladder is being effectively drained.

Question 15

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

Accepted Answer

Having the patient bear down can help relax the urethral sphincter, potentially easing the passage of the catheter.

Question 16

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

Accepted Answer

The nurse uses the nondominant hand to keep the labia spread apart continuously to maintain a sterile field while cleansing and inserting the catheter.

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

Cleaning the catheter from the meatus to the tubing helps prevent urinary tract infections, which are the most common complication of indwelling urinary catheters.

Question 18

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

Accepted Answer

Pressing the catheter adhesive helps ensure it adheres properly to the penis, reducing the risk of leakage or detachment.

Question 19

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 when cleaning the penis?

Accepted Answer

Holding the penis at a right angle to the body helps to straighten the urethra, making catheter insertion easier and reducing the risk of injury.

Question 20

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

Accepted Answer

A suprapubic catheter should drain urine continuously. If it does not, it may indicate a blockage or other issue that requires further investigation.

Quiz 19: Urinary Elimination