Nightingale BSN 205, Week 11, ISB: Elimination (Urinary Cath Lessons)
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| Which of the following demonstrate that further teaching is required to prevent an infection related to being catheterized? (Select all that apply.) | show 🗑
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| show | Aging can affect continence if the patient experiences impaired mobility or decreased muscle tone. The elderly are at increased risk for urinary tract infection because of retained urine in the bladder.
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| show | The kidneys assist in the detoxification of medication metabolites.
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| show | The nurse may use clean technique to insert an indwelling catheter."
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| show | What medications are you taking and when?"
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| show | 14 French, 5-mL balloon, latex catheter
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| A health care provider has ordered an indwelling catheter to be inserted for bedside drainage. Which of the following is NOT an expected indication for catheterization with an indwelling catheter? | show 🗑
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| A nurse is explaining the procedure for inserting an indwelling urinary catheter. Which of the following explanations regarding anchoring of the catheter would be most accurate? | show 🗑
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| show | Advance catheter another 1 to 2 inches and inflate balloon.
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| The nurse has inserted a catheter 7.5 cm (3 inches) in a female patient and obtains no urine return even though her bladder is distended. What action should the nurse take at this time? | show 🗑
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| show | Sterile cotton balls. Antiseptic solution. Water-soluble lubricant. Sterile forceps
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| show | The catheter is outside of the bladder. The catheter is inserted in the vagina rather than in the urethra of a female patient.
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| A nursing student is watching a nurse catheterize a female patient with an indwelling catheter. Which of the following, if it occurs, indicates a break in sterile technique? (Select all that apply.) | show 🗑
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| show | The nurse lubricates the catheter and places it back into the sterile tray when it uncoils and touches the bed. After the nurse cleans the labia, the labia become slippery and closed as the nurse attempts to obtain a clear view of the urethra.
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| show | Keeping the foreskin retracted after catheterization.
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| show | 16 French, 5-mL balloon
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| As part of catheter insertion assessment, where should the nurse palpate? | show 🗑
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| show | Ask the patient to take slow deep breaths while inserting the catheter slowly.
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| The nurse is catheterizing a female patient and obtains a clear amber urine return. As the nurse begins to inflate the balloon, the patient complains of pain and resistance is felt. What is the nurse’s best action? | show 🗑
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| show | The bedside drainage bag should only be emptied when it is full.”
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| The NAP documents “Peri-care given” next to “Urinary Catheter” on a patient with an indwelling urinary catheter. What is the best explanation of what the NAP did after application of clean gloves? The NAP: | show 🗑
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| show | The patient’s urine appears cloudy with a foul odor.
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| Identify the indicators of a UTI: (Select all that apply.) | show 🗑
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| show | Attach a 10 mL or larger syringe to the balloon port and allow the water to passively fill the syringe. Gently aspirate the syringe plunger if water remains in the balloon.
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| show | This is a normal occurrence after having a catheter in place for more than several days."
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| show | 1500 to 1700 (3:00 PM to 5:00 PM)
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| Which of the following is the best example of documentation on a patient with a urinary catheter? | show 🗑
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| show | I will measure and record the patient’s intake and output. I will apply ultrasound gel above the patient’s symphysis pubis." I should point the scanner head downward toward the bladder
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| The nurse works on a surgical unit. For which of the following patients would a nurse expect to perform a bladder scan? (Select all that apply.) | show 🗑
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| Four patients had a bladder scan for PVR. For which of the following patients would further investigation be required? | show 🗑
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| The nurse is to determine PVR on a patient who has been experiencing incontinence, but a bladder scanner is unavailable. What is the nurse’s best action? | show 🗑
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| show | This prevents the irrigating solution from going down into your drainage bag rather than into your bladder."
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| show | Ensure there are no kinks in drainage tubing, and if none, notify health care provider for possible bladder irrigation order.
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| pt returned from urological surgery with closed continuous bladder irrigation. The patient’s vital signs are within normal limits. The patient’s wife voices concern regarding the “bloody-red” appearance of the drainage. What is the nurse’s best response? | show 🗑
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| show | Performing hand hygiene and donning clean gloves. Priming infusion tubing w/ irrigating solution. Calculating urinary output as amount of irrigant infused subtracted from the amount in the drainage bag. Monitoring & emptying the drainage bag as needed.
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| show | Bladder irrigation may be used to instill medication into the bladder. Irrigating the bladder prevents any clots or sediment from blocking urinary drainage."
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| show | It is relatively safe and noninvasive. It is a convenient method of draining urine. It is used for male patients who are incontinent. It carries less risk of developing a UTI than an indwelling catheter.
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| show | Indwelling catheter insertion.
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| show | A regular condom catheter is removed every 3 days
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| show | Obtain another adhesive strip from condom catheter kit.
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| show | Redness and/or excoriation of the penis
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| show | The skin preparation solution prevents skin irritation and should be dry before the condom catheter is applied.”
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