Chapter 15: Elimination and Gastric Intubation
Cooper: Foundation of Nursing, 9th Edition
MULTIPLE CHOICE
1. After a Foley catheter has been removed, the nurse should assess the patient for:
a. hemorrhage.
b. constipation.
c. urinary retention.
d. bladder spasm.
ANS: C
While an indwelling urinary catheter is in place, the bladder loses tone and can retain urine
after the removal of the catheter.
DIF: Cognitive Level: Application REF: p. 364 OBJ: 1
TOP: Catheter removal KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
2. What would be the correct explanation of catheter care?
a. Cleansing the first 2 in of the catheter with soap and water every shift
b. Disinfecting the entire catheter with alcohol every shift
c. Lubricating the catheter with antiseptic lotion every 24 hours
d. Cleansing the meatal-catheter junction every 24 hours
ANS: A
The first 2 in of the catheter should be cleaned with soap and water every shift or more often
if the patient is incontinent. Alcohol and lotions are contraindicated. Catheter care should be
done every shift.
DIF: Cognitive Level: Application REF: p. 368 OBJ: 1
TOP: Catheter care KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment
3. During insertion of a Foley catheter, the patient grimaces as the balloon is inflated. What is the
immediate reaction of the nurse?
a.Withdraw the catheter.
b.Ask the patient to bear down.
c.Continue to inflate the balloon.
d.Advance the catheter into the bladder.
ANS: D
Grimacing is a sign of pain indicating that the balloon might be in the urethra instead of the
bladder. The catheter should be advanced before inflation.
DIF: Cognitive Level: Application REF: p. 360 OBJ: 1
TOP: Catheterization KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
4. When explaining the difference between a colostomy and an ileostomy, the nurse explains
which of the following about an ileostomy?
Cooper: Foundation of Nursing, 9th Edition
MULTIPLE CHOICE
1. After a Foley catheter has been removed, the nurse should assess the patient for:
a. hemorrhage.
b. constipation.
c. urinary retention.
d. bladder spasm.
ANS: C
While an indwelling urinary catheter is in place, the bladder loses tone and can retain urine
after the removal of the catheter.
DIF: Cognitive Level: Application REF: p. 364 OBJ: 1
TOP: Catheter removal KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
2. What would be the correct explanation of catheter care?
a. Cleansing the first 2 in of the catheter with soap and water every shift
b. Disinfecting the entire catheter with alcohol every shift
c. Lubricating the catheter with antiseptic lotion every 24 hours
d. Cleansing the meatal-catheter junction every 24 hours
ANS: A
The first 2 in of the catheter should be cleaned with soap and water every shift or more often
if the patient is incontinent. Alcohol and lotions are contraindicated. Catheter care should be
done every shift.
DIF: Cognitive Level: Application REF: p. 368 OBJ: 1
TOP: Catheter care KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment
3. During insertion of a Foley catheter, the patient grimaces as the balloon is inflated. What is the
immediate reaction of the nurse?
a.Withdraw the catheter.
b.Ask the patient to bear down.
c.Continue to inflate the balloon.
d.Advance the catheter into the bladder.
ANS: D
Grimacing is a sign of pain indicating that the balloon might be in the urethra instead of the
bladder. The catheter should be advanced before inflation.
DIF: Cognitive Level: Application REF: p. 360 OBJ: 1
TOP: Catheterization KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
4. When explaining the difference between a colostomy and an ileostomy, the nurse explains
which of the following about an ileostomy?
