WEEK 6 170A CLINICAL SKILLS STUDYGUIDE QUESTIONS AND CORRECT
ANSWERS
Question:
1. Which action would the nurse take to reduce the risk for a catheter-associated urinary
tract infection (CAUTI) in a patient with an indwelling urinary catheter?
A. Wear clean gloves when inserting the catheter.
B. Inflate the balloon on the catheter before using it.
C. Use the smallest-size catheter possible.
D. Empty the urine by disconnecting the catheter from the collection bag.
Answer:
C-To reduce the risk of CAUTI in a patient with an indwelling urinary catheter, the nurse would
use the smallest-size catheter possible. To reduce the risk of CAUTI, the nurse would wear sterile,
not simply clean, gloves to insert the indwelling urinary catheter. Inflating the balloon before
inserting an indwelling urinary catheter would not reduce the risk of CAUTI. To reduce the risk of
CAUTI in a patient with an indwelling urinary catheter, the urine collection device must remain a
closed system. To keep the system completely closed, the urine must be removed from the
device connected to the bag and not by disconnecting the catheter from the drainage bag
Question:
2. Which action(s) would minimize the patient's risk for injury during insertion of an
indwelling urinary catheter?
A. Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based
substances
B. Thoroughly cleansing the patient's perineal area with povidone-iodine solution before
inserting the catheter
C. Performing proper hand hygiene and applying sterile gloves before inserting the catheter
the patient reports pain at any time during the procedure
Answer:
A-Assessing the patient for allergies would minimize the patient's risk for injury. Serious allergic
reactions may occur if the patient has an allergy to latex, antiseptic, tape, or iodine-based
cleanser. Thoroughly cleansing the patient's perineal area reduces the risk for infection during
catheter insertion but does not reduce the patient's risk for injury. Proper hand hygiene and
sterile gloving reduce the risk for infection during catheter insertion but do not reduce the
patient's risk for injury. Insertion of a urinary catheter is uncomfortable, but it is not always
necessary to terminate the procedure if the patient reports a tolerable level of pain during the
process.
Question:
3. Which statement best illustrates the nurse's understanding of the role of nursing assistive
personnel (NAP) when inserting an indwelling urinary catheter in a female patient?
A. "Please direct the light to better illuminate the patient's perineal area."
B. "You need to be comfortable inserting a catheter in a patient of her size."
C. "See if a size 14-French catheter is big enough."
D. "Find out if the patient has any allergies to latex or iodine."
,Answer:
A-No aspect of the skill of indwelling urinary catheter insertion may be delegated to NAP, but the
nurse may delegate related tasks, such as redirecting the lighting during the procedure.
Indwelling catheter insertion cannot be delegated to NAP. Catheter selection cannot be delegated
to NAP. Assessment of patient allergies cannot be delegated to NAP.
Question:
4. The nurse has completed the initial inspection of the patient's perineum and is preparing
to insert an indwelling urinary catheter. Which action would the nurse complete next?
A. Begin to establish a sterile field. urine drainage bag.
C. Remove soiled gloves, and perform hand hygiene.
D. Center the drape over the patient's labia.
Answer:
C-The nurse would remove soiled gloves and perform hand hygiene as the next step. The nurse
would not begin to establish a sterile field next. The nurse would not open and assemble the
drainage bag next. The nurse would not center the drape over the patient's labia as the next
step.
Question:
5. A female patient placed in the dorsal recumbent position for the insertion of an indwelling
urinary catheter tells the nurse that she "doesn't feel comfortable in this position" and that
her "back really hurts." What is the nurse's best response?
A. Reassure the patient that the procedure will take only a few minutes.
B. Promise to reposition the patient as soon as the catheter has been inserted.
C. Reposition the patient in a side-lying position, with her upper leg flexed at the knee and
hip.
D. Explain to the patient that the position will allow the catheter insertion to be more
efficient.
Answer:
C-The side-lying position is an acceptable alternative that may be more comfortable for the
patient. Reassuring the patient that the procedure will be brief does not address the patient's
comfort level during the catheter insertion. Offering to reposition the patient after the procedure
does not address the patient's comfort level during the catheter insertion. Explaining to the
patient that the dorsal recumbent position is more efficient does not address the patient's
comfort level during the catheter insertion.
Question:
6. nursing assistive personnel (NAP) the perineal care of a female patient who is totally
dependent and confined to bed. Which statement by the NAP requires the nurse's follow-up?
A. "I'll ask for assistance if I need help positioning her."
B. "I'll see if she's up to the care right now."
C. "I'll let you know if I notice any signs of redness or discharge."
D. "I'll be sure to use hot, soapy water, since she has been incontinent."
Answer:
, be used when cleansing the perineal area, so this statement requires the nurse's follow-up.
Positioning a totally dependent patient is likely to require more than one person, so this requires
no follow-up. It is appropriate to evaluate the patient's ability and willingness to have the care
performed at this time, so this requires no follow-up. Observing the patient's perineal area for
signs of skin damage or discharge is appropriate, so this requires no follow-up.
Question:
7. The nurse is preparing to provide perineal care for a female patient who is on bed rest.
Which patient position should the nurse use for this care?
A. Supine
B. Prone
C. Side-lying
D. Dorsal recumbent
Answer:
D-Dorsal recumbent is the correct patient position to use when performing perineal care. The
supine, prone, and side-lying positions are not used when performing perineal care.
Question:
8. As the nurse is preparing to provide perineal care to a female patient with limited modo
that myself." Which action would be the priority?
A. Provide all the necessary supplies and linen for this task.
B. Assess the patient's ability to perform proper perineal care.
C. Ensure that the patient has privacy while performing perineal care.
D. Document any complaints of irritation or pain in the perineal area.
Answer:
B-Determining the appropriateness of self-care by assessing the patient's ability to provide her
own perineal care is the priority action. Although it is a nursing responsibility to protask, ensuring
the patient's privacy, and documenting patient complaints, doing so would not take priority over
assessing the patient's ability to perform perineal care.
Question:
9. How can the nurse promote infection control while providing perineal care for a female
patient who has a catheter?
A. By avoiding the application of tension on the catheter.
B. By patting, not rubbing, the skin dry after thoroughly rinsing it.
C. By cleansing the patient's labia from the pubic area toward the rectum.
D. By using warm water to cleanse the patient's entire perineal area. male patient's perineal
care to nursing assistive personnel (NAP). Which instruction would the nurse give to ensure
the NAP's safety while performing this care?
A. Wear sterile gloves.
B. Wear clean gloves.
C. Wear an isolation gown.
D. Use hot water.
Answer:
ANSWERS
Question:
1. Which action would the nurse take to reduce the risk for a catheter-associated urinary
tract infection (CAUTI) in a patient with an indwelling urinary catheter?
A. Wear clean gloves when inserting the catheter.
B. Inflate the balloon on the catheter before using it.
C. Use the smallest-size catheter possible.
D. Empty the urine by disconnecting the catheter from the collection bag.
Answer:
C-To reduce the risk of CAUTI in a patient with an indwelling urinary catheter, the nurse would
use the smallest-size catheter possible. To reduce the risk of CAUTI, the nurse would wear sterile,
not simply clean, gloves to insert the indwelling urinary catheter. Inflating the balloon before
inserting an indwelling urinary catheter would not reduce the risk of CAUTI. To reduce the risk of
CAUTI in a patient with an indwelling urinary catheter, the urine collection device must remain a
closed system. To keep the system completely closed, the urine must be removed from the
device connected to the bag and not by disconnecting the catheter from the drainage bag
Question:
2. Which action(s) would minimize the patient's risk for injury during insertion of an
indwelling urinary catheter?
A. Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based
substances
B. Thoroughly cleansing the patient's perineal area with povidone-iodine solution before
inserting the catheter
C. Performing proper hand hygiene and applying sterile gloves before inserting the catheter
the patient reports pain at any time during the procedure
Answer:
A-Assessing the patient for allergies would minimize the patient's risk for injury. Serious allergic
reactions may occur if the patient has an allergy to latex, antiseptic, tape, or iodine-based
cleanser. Thoroughly cleansing the patient's perineal area reduces the risk for infection during
catheter insertion but does not reduce the patient's risk for injury. Proper hand hygiene and
sterile gloving reduce the risk for infection during catheter insertion but do not reduce the
patient's risk for injury. Insertion of a urinary catheter is uncomfortable, but it is not always
necessary to terminate the procedure if the patient reports a tolerable level of pain during the
process.
Question:
3. Which statement best illustrates the nurse's understanding of the role of nursing assistive
personnel (NAP) when inserting an indwelling urinary catheter in a female patient?
A. "Please direct the light to better illuminate the patient's perineal area."
B. "You need to be comfortable inserting a catheter in a patient of her size."
C. "See if a size 14-French catheter is big enough."
D. "Find out if the patient has any allergies to latex or iodine."
,Answer:
A-No aspect of the skill of indwelling urinary catheter insertion may be delegated to NAP, but the
nurse may delegate related tasks, such as redirecting the lighting during the procedure.
Indwelling catheter insertion cannot be delegated to NAP. Catheter selection cannot be delegated
to NAP. Assessment of patient allergies cannot be delegated to NAP.
Question:
4. The nurse has completed the initial inspection of the patient's perineum and is preparing
to insert an indwelling urinary catheter. Which action would the nurse complete next?
A. Begin to establish a sterile field. urine drainage bag.
C. Remove soiled gloves, and perform hand hygiene.
D. Center the drape over the patient's labia.
Answer:
C-The nurse would remove soiled gloves and perform hand hygiene as the next step. The nurse
would not begin to establish a sterile field next. The nurse would not open and assemble the
drainage bag next. The nurse would not center the drape over the patient's labia as the next
step.
Question:
5. A female patient placed in the dorsal recumbent position for the insertion of an indwelling
urinary catheter tells the nurse that she "doesn't feel comfortable in this position" and that
her "back really hurts." What is the nurse's best response?
A. Reassure the patient that the procedure will take only a few minutes.
B. Promise to reposition the patient as soon as the catheter has been inserted.
C. Reposition the patient in a side-lying position, with her upper leg flexed at the knee and
hip.
D. Explain to the patient that the position will allow the catheter insertion to be more
efficient.
Answer:
C-The side-lying position is an acceptable alternative that may be more comfortable for the
patient. Reassuring the patient that the procedure will be brief does not address the patient's
comfort level during the catheter insertion. Offering to reposition the patient after the procedure
does not address the patient's comfort level during the catheter insertion. Explaining to the
patient that the dorsal recumbent position is more efficient does not address the patient's
comfort level during the catheter insertion.
Question:
6. nursing assistive personnel (NAP) the perineal care of a female patient who is totally
dependent and confined to bed. Which statement by the NAP requires the nurse's follow-up?
A. "I'll ask for assistance if I need help positioning her."
B. "I'll see if she's up to the care right now."
C. "I'll let you know if I notice any signs of redness or discharge."
D. "I'll be sure to use hot, soapy water, since she has been incontinent."
Answer:
, be used when cleansing the perineal area, so this statement requires the nurse's follow-up.
Positioning a totally dependent patient is likely to require more than one person, so this requires
no follow-up. It is appropriate to evaluate the patient's ability and willingness to have the care
performed at this time, so this requires no follow-up. Observing the patient's perineal area for
signs of skin damage or discharge is appropriate, so this requires no follow-up.
Question:
7. The nurse is preparing to provide perineal care for a female patient who is on bed rest.
Which patient position should the nurse use for this care?
A. Supine
B. Prone
C. Side-lying
D. Dorsal recumbent
Answer:
D-Dorsal recumbent is the correct patient position to use when performing perineal care. The
supine, prone, and side-lying positions are not used when performing perineal care.
Question:
8. As the nurse is preparing to provide perineal care to a female patient with limited modo
that myself." Which action would be the priority?
A. Provide all the necessary supplies and linen for this task.
B. Assess the patient's ability to perform proper perineal care.
C. Ensure that the patient has privacy while performing perineal care.
D. Document any complaints of irritation or pain in the perineal area.
Answer:
B-Determining the appropriateness of self-care by assessing the patient's ability to provide her
own perineal care is the priority action. Although it is a nursing responsibility to protask, ensuring
the patient's privacy, and documenting patient complaints, doing so would not take priority over
assessing the patient's ability to perform perineal care.
Question:
9. How can the nurse promote infection control while providing perineal care for a female
patient who has a catheter?
A. By avoiding the application of tension on the catheter.
B. By patting, not rubbing, the skin dry after thoroughly rinsing it.
C. By cleansing the patient's labia from the pubic area toward the rectum.
D. By using warm water to cleanse the patient's entire perineal area. male patient's perineal
care to nursing assistive personnel (NAP). Which instruction would the nurse give to ensure
the NAP's safety while performing this care?
A. Wear sterile gloves.
B. Wear clean gloves.
C. Wear an isolation gown.
D. Use hot water.
Answer:
