1. The nurse is assessing a patient whose 24-hour output is 2400 mL. Which finding reflects the nurse's understanding of urine output? Show a. Increased output c. Normal output The average output range for adult urinary output averages between 2200 and 2700 mL in 24 hours. 2. On the basis of the nurse's assessment of kidney function for an adult patient, which finding is normal? a. 10 mL/hr c. 30 mL/hr Minimum average hourly output is 30 mL. 3. Which activities related to urinary elimination may be delegated to a nursing assistive personnel (NAP)? a. Catheterization b. Positioning the patient Nursing assistive personnel (NAP) may position the patient, focus lighting for the procedure, and enhance the patient's comfort during the procedure through measures such as holding the patient's hand or keeping the patient warm. The nurse uses sterile asepsis when inserting an indwelling or straight catheter to reduce the risk for bladder infection. The nurse evaluates possible alternatives to catheter use, and assessment is the responsibility of the nurse. 4. The nurse is planning care for a 12-year-old female patient who needs a Foley catheter inserted. It is most important for the nurse to use a catheter of which size French (Fr)? a. 5 to 6 Fr c. 12 Fr Gender and age determine catheter size. A 12-Fr catheter may be considered for use in young girls. The prescriber may order a larger size. For infants, 5 to 6 Fr is generally used; for children, 8 to 10 Fr with a 3-mL balloon is used; and 14 to 16 Fr is indicated for adult women. 5. The nurse notes that urine does not flow after a female patient is catheterized. The nurse believes that the catheter has been placed into the vagina. Which action should the nurse take? a. Remove the catheter and reinsert it. c. Leave the catheter in place and insert another one. If no urine appears, check whether the catheter is in the vagina. If misplaced, leave the catheter in the vagina as a landmark indicating where not to insert it, and insert another catheter into the meatus. Reinserting a catheter that has already been contaminated by vaginal exposure could lead to urinary tract infection. 6. When the balloon on an indwelling urinary catheter is inflated and the patient expresses discomfort, it is essential for the nurse to take which action? a. Remove the catheter. c. Aspirate the fluid from the balloon and advance the catheter. If resistance to inflation is noted, or if the patient complains of pain, the balloon may not be entirely within the bladder. Stop inflation, aspirate any fluid injected into the balloon, and advance the catheter a little farther before attempting again to inflate. 7. The nurse is caring for a patient who has an indwelling urinary catheter. Which intervention is most important to include in this patient's plan of care? a. Maintaining tension on the tubing c. Cleaning in a circular motion from the meatus down the catheter Using a clean washcloth, wipe in a circular motion along the length of the catheter for about 10 cm (4 inches). Allow slack in the catheter so movement does not create tension on it. Empty the drainage bag, and record amounts at least every 3 to 6 hours. The drainage bag must be below the level of the bladder; do not place the bag on the side rails of the bed. 8. The nurse has been ordered to perform closed intermittent irrigation of a patient's indwelling urinary catheter. Which intervention is indicative of safe practice? a. Applies sterile gloves. d. Determines the amount of urinary drainage by subtracting the amount of irrigant from the total output. Calculate the fluid used to irrigate the bladder and catheter, and subtract from the volume drained to determine accurate urinary output. Closed intermittent irrigation does not require the use of sterile gloves. The typical amount of irrigant used is 30 to 50 mL and the tubing is clamped during the process. 9. When evaluating the health care team member's ability to apply a condom catheter, it is most important for the nurse to provide further instruction for which intervention? a. Clipping of hair at the
base of the penis c. Using regular adhesive tape to hold the catheter in place Use of an adhesive strip not designed for sheath application may be inflexible and may impede circulation to the penis. Clip hair at the base of the penis. Hair adheres to the condom and is pulled during condom removal or may get caught in rubber as the condom catheter is applied. Apply skin preparation to the penis and allow it to dry. Leave 1 to 2 inches of space between the tip of the glans penis and the end of the condom. 10. When providing care for a patient with a suprapubic catheter who has acquired a urinary tract infection (UTI), which intervention is most important for the nurse to implement? a. Using clean technique d. Promoting intake of 2200 mL of fluid per day Encourage the patient with a UTI to drink at least 2200 mL of fluid per day. The insertion site is cleansed in a circular swabbing pattern so as not to disturb the tubing. Standard care requires the use of clean gloves and securing the catheter to the abdomen. 11. Which symptom is the patient with fluid overload likely to exhibit? a. Oliguria b. Distended neck veins Cardiovascular signs of fluid volume excess include bounding pulse rate, normal blood pressure with or without orthostatic changes, third heart sound (S3), and distended neck veins. Oliguria is a renal sign of fluid volume deficit. Increased skin temperature is a sign of fluid volume deficit. Increased urine specific gravity is a renal sign of fluid volume deficit. 12. When observing a patient for symptoms of dehydration, the nurse should observe which assessment? a. Increased salivation d. Decreased capillary filling Cardiovascular signs of fluid volume deficit include increased pulse rate, weak pulse, hypotension, decreased pulse volume/pressure, decreased capillary filling, and increased hematocrit. Increased salivation and periorbital edema are signs of fluid volume excess. Diuresis is a renal sign of fluid volume excess. 13. When providing care for a patient in need of an indwelling catheter, the nurse understands that which of the following is an indication for this need? a. Presence of stage III and IV pressure ulcers a. Presence of stage III and IV pressure ulcers Indications for an indwelling catheter include (1) the presence of stage III and IV pressure ulcers that cannot heal because of continual incontinence, and (2) the need for accurate measurement of urinary output in critically ill patients. The incidence of catheter-associated UTI significantly decreases when the nurse gives the prescriber daily reminders to remove unnecessary catheters and suggests the use of alternative noninvasive treatments to manage urinary elimination. 14. The nurse receives an order to insert a Foley catheter. In obtaining a catheter of the right size, the nurse is aware that large catheters can lead to which complication? a. Urethral damage a. Urethral damage Large catheters (larger than 16 Fr) can distend the urethra and permanently damage the urethra and bladder neck, as well as cause bladder spasms and leaking around the catheter. Use a catheter of the smallest size possible to minimize trauma and promote adequate drainage of the periurethral glands. This will decrease the risk for infection. 15. The nurse is caring for a patient who has an indwelling catheter attached to a drainage bag. To achieve the desired outcome of this procedure, which nursing action should be taken? a. Make sure the tubing has dependent loops to gather urine. b. Make sure the tubing is coiled and secured to the bed. Check the drainage tubing and the bag to make sure that the tubing does not have dependent loops and the bag is not positioned above the level of the bladder. Check to make sure that the tubing is coiled and is secured to the bed linen, is free of kinks, and is not clamped, and that the patient is not lying on it. 16. The nurse is caring for a patient who is experiencing inadequate bladder emptying. To determine postvoid residual, which technique is most important for the nurse to implement? a. Bladder scanner a. Bladder scanner The bladder scan is most commonly used to measure postvoid residual (PVR); it is the least invasive method of making this determination. 17. The nurse is preparing the patient for a bladder scan to determine postvoid residual (PVR). Which of the following is part of the preparation? a. Limit food intake for 2 hours before the scan. b. Begin scan 10 minutes after the patient has voided. The nurse will assist the patient to void, then wait 10 minutes before administering the bladder scan. There is no need to limit either food or fluids before the test. Since the test is completely noninvasive, there is no need to administer an analgesic beforehand. 1. In assisting a male patient in using a urinal, which of the following actions should the nurse take? (Select all that apply.) a. Assess for orthostatic hypotension. a. Assess for orthostatic hypotension. To assist the patient in using a urinal, the nurse should assess the patient's normal urinary elimination habits and look for periods of incontinence. Always determine mobility status before having a patient stand to void, and assess for orthostatic hypotension if the patient has been on prolonged bed rest. If the patient is able to handle the urinal himself, allow him privacy. If the patient is unable to handle the urinal, the nurse will assist by holding it.\ 2. The nurse has inserted an indwelling catheter and secured the catheter to the patient's thigh, making sure that there is enough slack that movement will not create tension on the catheter. The nurse understands that the chief purpose of properly securing Foley catheters is to obtain which outcome? (Select all that apply.) a. Minimized risk for bleeding a. Minimized risk for bleeding Securing the catheter will minimize accidental dislodgment. It also will minimize risks for bleeding, trauma, meatal necrosis, and bladder spasms from pressure and traction. END OF CHAPTER QUESTIONS END OF CHAPTER QUESTIONS
Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order: 1. Insert and advance catheter 5. Drape patient with the sterile square and fenestrated drapes. The nurse is preparing to remove an indwelling urinary catheter. Which nursing interventions should the nurse implement? (Select all the apply) 1. Attach a 3-mL syringe to the inflation port 2. Allowing the balloon to drain into the syringe by gravity By allowing the balloon to drain by gravity, the development of creases or ridges in the balloon may be avoided, thus minimizing trauma to the urethra during withdrawal. All patients who have a catheter removed should have their voiding monitored. The best way to do this is with a voiding record or bladder diary. The size syringe used to deflate the balloon is dictated by the size of the balloon. In the adult patient balloon sizes are either 10 mL or 30 mL. Catheters should be pulled out slowly and smoothly. There is no evidence to support clamping catheters before removal. Which nursing interventions are appropriate in the care of a patient with a newly inserted suprapubic catheter? (Select all that apply) 1. Using sterile technique, clean the skin close to the catheter with a circular motion. 1. Using sterile technique, clean the skin close to the catheter with a circular motion. A new suprapubic catheter insertion site is a surgical incision and should be treated similarly to other incisions, which includes sterile dressing change and inspection of the site for signs of infection. To minimize trauma and increase comfort, the catheter should be anchored to the abdomen. Wiping the catheter toward the skin violates principals of asepsis. Tension to the catheter should be avoided in all circumstances to minimize discomfort and potential for damage to the bladder wall. EVOLVE ONLINE QUESTIONS EVOLVE ONLINE QUESTIONS What is the best nursing action when there is no urine flow after an indwelling urinary catheter is inserted into a female patient? A. Remove the catheter and start all over with a new kit and catheter. B. Determine whether the catheter is in the vagina, leave it there, and start over with a new catheter. If misplaced, leave the catheter in the vagina as a landmark, indicating where not to insert, and insert another sterile catheter. Pulling the catheter back and reinserting is poor technique, increasing the risk for CAUTI. Place in appropriate order the following steps related to open intermittent irrigation of a catheter. A. Position sterile drape under catheter. E. Remove syringe, lower catheter, and
allow solution to drain into basin. Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)? A. Daily cleansing of the urinary meatus A. Daily cleansing of the urinary meatus Evidence-based interventions shown to decrease the risk for CAUTI include ensuring a free flow of urine in the catheter to the bag, daily perineal hygiene and using a separate receptacle for each patient when emptying the Foley. Irrigation and changing the bag will increase the risk for CAUTI through repeated opening of the sterile catheter drainage system. Which intervention is appropriate when an indwelling urinary catheter is secured in a male patient? A. Secure the catheter drainage tubing to the lower leg. C. Tape the catheter tubing to the lower abdomen, avoiding traction. Securing the catheter, not the drainage tubing, reduces the risk of urethral erosion, CAUTI, or accidental catheter removal. Attachment of the securement device at the bifurcation is recommended to prevent catheter occlusion. Securement of the male catheter to the abdomen reduces traction on the urethra and prevents urethral injury. Catheter traction should always be avoided to minimize risk for urethral trauma. When performing catheter care, what step helps prevent traction on the catheter and CAUTI? A. Wash the meatus with soap and water. C. Grasp the catheter with two fingers to stabilize the catheter. All options help prevent CAUTI, but only option "C" prevents unnecessary traction on the catheter. Pulling on the catheter causes discomfort for the patient and can damage the urethra and the bladder neck. How do you assess indwelling catheter?Insert catheter into the urethral opening, upward at approximately 30 degree angle until urine begins to flow. Inflate the balloon slowly using sterile water to the volume recommended on the catheter. Check that child feels no pain. If there is pain, it could indicate the catheter is not in the bladder.
What is the importance of indwelling urinary catheter care?Because the catheter goes from the outside world into your body, it's important to keep it clean. Germs that get inside your body can cause infection. Follow the tips below, along with your doctor's instructions, to care for your catheter.
What should be included in the management of a patient with an indwelling urinary catheter?Daily catheter care should include: Labeling on bag insertion date, time and place (e.g. OR, ER). Maintain a closed urinary drainage system to prevent introduction of bacteria into the urinary tract. Adequately secure and anchor the catheter to prevent urethral and bladder-neck tension.
What is the most common problem associated with indwelling catheter use?A urinary tract infection is the most common problem for people with an indwelling urinary catheter. Call your provider if you have signs of an infection, such as: Pain around your sides or lower back.
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Which assessment is most important for the safety of a patient with an indwelling urinary catheter
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