Potter: Fundamentals of Nursing, 9th Edition Chapter 46 Urinary Elimination

When assessing a patient's first voided urine of the day, which finding should be reported to the health care provider? - Answer - Light pink urine R: Light pink urine indicates the presence of blood in the urine, which is never a normal finding. First voided urine can normally be slightly cloudy and darker in color. Pale yellow urine indicates normal finding. What is a critical step when inserting an indwelling catheter into a male patient? - Answer - Advance the catheter to the bifurcation of the drainage and balloon ports R: Advancing the catheter to the bifurcation avoids inflating the catheter balloon in the prostatic urethra causing trauma and pain. Catheter balloons are never inflated with saline. Securing the catheter drainage tubing to the bed sheets increases the risk for accidental pulling or tension on the catheter. The advancement of the catheter until flows and then inserting ¼ inch more is not unique to the male patient. Which nursing intervention minimizes the risk for trauma and infection when applying an external/condom catheter? - Answer - Wash with soap and water prior to applying the condom type catheter. R: Hygiene minimizes skin irritation. There needs to be 2.5 to 5 cm (1 to 2 inches) of space between tip of the glans penis and the end of the catheter. Excess space may cause pooling of urine causing excessive exposure to urine. Shaving the pubic area increases the risk for skin irritation. The condom should be secure but not tight. Application of tape is contraindicated because it could interfere with circulation increasing risk for necrosis of the penis. What instructions should the nurse give the NAP concerning a patient who has had an indwelling urinary catheter removed that day? - Answer - Report the time and amount of first voiding. R: In order to adequately assess bladder function after a catheter is removed; voiding frequency and amount should be monitored. Unless contraindicated, fluids should be encouraged. To promote normal micturition, patients should be placed in as normal a posture for voiding as possible. Suprapubic tenderness and pain are possible indicators of urinary retention and/or a UTI. A post-operative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention? - Answer - Assess the intake and output