BSN206 Quiz 7 Urinary and Gastrointestinal
Elimination Protocols (Module 7 50 QUESTIONS
AND CORRECT ANSWERS WITH RATIONALES)
covers urinary catheter insertion criteria, incontinence management, enema protocols, ostomy
care, and specimen handling.
1. Which indication is considered valid and evidence-based for inserting an indwelling
urinary catheter?
A) Managing routine urinary incontinence for nursing staff convenience
B) Accurate measurement of urinary output in critically ill patients
C) Obtaining a routine clean-catch urine specimen from an alert client
D) Substituting for comprehensive mobility therapy in an older adult
Rationale: Indwelling catheters carry a high risk of CAUTI (Catheter-Associated Urinary
Tract Infection). Legitimate clinical uses include monitoring acute fluid balance in
critical care, managing acute urinary retention, or supporting healing in open sacral
wounds.
1. A nurse is preparing to insert a urinary catheter for a female patient. What is the correct
anatomical orientation of the female urethra?
A) Superior to the clitoris
B) Between the clitoris and the vaginal orifice
C) Inside the vaginal canal posterior wall
D) Inferior to the anus perimeter
Rationale: The female urethral meatus is located between the clitoris superiorly and the
vaginal orifice inferiorly. Accurate anatomical mapping prevents accidental insertion into
the vagina.
1. During the insertion of a urinary catheter in a male patient, the nurse notes resistance as
the catheter passes through the prostatic urethra. What should the nurse do first?
A) Force the catheter forward quickly to pass the obstruction
B) Pull the catheter out immediately and abandon the procedure
C) Ask the patient to take deep breaths to relax the sphincter while applying gentle,
steady pressure
D) Inflate the retention balloon right away to clear the path
Rationale: Moderate resistance may be encountered due to sphincter spasms or prostatic
enlargement. Asking the patient to breathe deeply helps relax muscles, allowing gentle,
steady progression without forcing the line.
1. To prevent traction and trauma to the bladder neck, the nurse should secure an indwelling
urinary catheter to which area of the patient's body?
, A) The movable lower footboard bed rail slats
B) The upper thigh for women or the abdomen/upper thigh for men
C) The side-lying mattress strap line
D) The ankle structure using an elastic wrap
Rationale: Securing the catheter tubing to the thigh or abdomen prevents pulling and
friction against the bladder neck and urethral meatus, which reduces the risk of tissue
erosion.
1. Where should the drainage bag of an indwelling urinary catheter be hung to maintain
optimal safety and function?
A) On the side rail so the patient can monitor it easily
B) Flat on the floor directly beneath the center of the bed
C) On the bed frame below the level of the bladder
D) Suspended from an IV pole 3 feet above the mattress height
Rationale: The collection bag must be kept below the level of the bladder to allow gravity
drainage and prevent contaminated urine from refluxing back into the bladder. It must
never touch the floor to avoid tracking external microbes.
1. A nurse notes that a patient’s indwelling catheter has drained no urine over the past 3
hours. What is the nurse's first action?
A) Perform an immediate sterile catheter irrigation pass
B) Check the tubing for kinks, loops, or compression twists
C) Notify the healthcare provider to report kidney failure
D) Force the patient to drink 1,000 mL of fluid immediately
Rationale: Positional blockages are the most common cause of sudden drop-offs in urine
flow. Checking for visible kinks or structural twisting should always precede invasive
interventions.
1. Which diagnostic test requires a nurse to collect a clean-catch or midstream urine sample
to identify specific pathogen colonization?
A) 24-hour total quantitative protein profile
B) Standard urine specific gravity reagent strip test
C) Urine Culture and Sensitivity (C&S)
D) Guaiac fecal occult blood verification
Rationale: A Culture and Sensitivity test isolates specific bacteria causing a UTI and
determines effective antibiotic therapies. A midstream collection minimizes
contamination from the external perineal skin flora.
1. When collecting a 24-hour urine specimen collection, what step must the nurse take
regarding the first morning urine void?
A) Discard the first morning void, note the time, and collect all subsequent urine for 24
hours
Elimination Protocols (Module 7 50 QUESTIONS
AND CORRECT ANSWERS WITH RATIONALES)
covers urinary catheter insertion criteria, incontinence management, enema protocols, ostomy
care, and specimen handling.
1. Which indication is considered valid and evidence-based for inserting an indwelling
urinary catheter?
A) Managing routine urinary incontinence for nursing staff convenience
B) Accurate measurement of urinary output in critically ill patients
C) Obtaining a routine clean-catch urine specimen from an alert client
D) Substituting for comprehensive mobility therapy in an older adult
Rationale: Indwelling catheters carry a high risk of CAUTI (Catheter-Associated Urinary
Tract Infection). Legitimate clinical uses include monitoring acute fluid balance in
critical care, managing acute urinary retention, or supporting healing in open sacral
wounds.
1. A nurse is preparing to insert a urinary catheter for a female patient. What is the correct
anatomical orientation of the female urethra?
A) Superior to the clitoris
B) Between the clitoris and the vaginal orifice
C) Inside the vaginal canal posterior wall
D) Inferior to the anus perimeter
Rationale: The female urethral meatus is located between the clitoris superiorly and the
vaginal orifice inferiorly. Accurate anatomical mapping prevents accidental insertion into
the vagina.
1. During the insertion of a urinary catheter in a male patient, the nurse notes resistance as
the catheter passes through the prostatic urethra. What should the nurse do first?
A) Force the catheter forward quickly to pass the obstruction
B) Pull the catheter out immediately and abandon the procedure
C) Ask the patient to take deep breaths to relax the sphincter while applying gentle,
steady pressure
D) Inflate the retention balloon right away to clear the path
Rationale: Moderate resistance may be encountered due to sphincter spasms or prostatic
enlargement. Asking the patient to breathe deeply helps relax muscles, allowing gentle,
steady progression without forcing the line.
1. To prevent traction and trauma to the bladder neck, the nurse should secure an indwelling
urinary catheter to which area of the patient's body?
, A) The movable lower footboard bed rail slats
B) The upper thigh for women or the abdomen/upper thigh for men
C) The side-lying mattress strap line
D) The ankle structure using an elastic wrap
Rationale: Securing the catheter tubing to the thigh or abdomen prevents pulling and
friction against the bladder neck and urethral meatus, which reduces the risk of tissue
erosion.
1. Where should the drainage bag of an indwelling urinary catheter be hung to maintain
optimal safety and function?
A) On the side rail so the patient can monitor it easily
B) Flat on the floor directly beneath the center of the bed
C) On the bed frame below the level of the bladder
D) Suspended from an IV pole 3 feet above the mattress height
Rationale: The collection bag must be kept below the level of the bladder to allow gravity
drainage and prevent contaminated urine from refluxing back into the bladder. It must
never touch the floor to avoid tracking external microbes.
1. A nurse notes that a patient’s indwelling catheter has drained no urine over the past 3
hours. What is the nurse's first action?
A) Perform an immediate sterile catheter irrigation pass
B) Check the tubing for kinks, loops, or compression twists
C) Notify the healthcare provider to report kidney failure
D) Force the patient to drink 1,000 mL of fluid immediately
Rationale: Positional blockages are the most common cause of sudden drop-offs in urine
flow. Checking for visible kinks or structural twisting should always precede invasive
interventions.
1. Which diagnostic test requires a nurse to collect a clean-catch or midstream urine sample
to identify specific pathogen colonization?
A) 24-hour total quantitative protein profile
B) Standard urine specific gravity reagent strip test
C) Urine Culture and Sensitivity (C&S)
D) Guaiac fecal occult blood verification
Rationale: A Culture and Sensitivity test isolates specific bacteria causing a UTI and
determines effective antibiotic therapies. A midstream collection minimizes
contamination from the external perineal skin flora.
1. When collecting a 24-hour urine specimen collection, what step must the nurse take
regarding the first morning urine void?
A) Discard the first morning void, note the time, and collect all subsequent urine for 24
hours
