NUR 1229- Foley catheter (Exam 1) Questions With
Complete Solutions
A sterile catheter kit contains: Correct Answer -sterile gloves
-sterile drapes
-sterile catheter
-antiseptic cleaner (betadine or chlorohexidine)
-cotton balls
-antiseptic swabs
-lube
-forceps
-prefilled syringe with sterile water (10cc or whatever is the
balloons holding capacity)
-sterile basin
-sterile specimen container
-leg securement device
Care for the catheter patient Correct Answer -handwashing
-correct insertion with sterility
-female- thigh securement
-male abdomen securement (avoid tugging on urethra, more
comfortable and decreased infection risk)
-drainage bag below bladder to prevent back flow
-tube and bag off ground and on stationary object
-keep closed until open for emptying and irrigation
-urine specimens collected by aseptic and closed method
-keep free from obstruction
-avoid irrigating unless MD ordered or to remove obstruction
-adequate fluid intake
-empty bag at 1/2 to 2/3 full
-don't touch spout of bag to collection device
,-clean bag and provide peri care daily
-strict I&O followed
Cather insertion documentation: Correct Answer -date
-time
-size of cath
-patient response
-sterile technique used!
-how much water (Not NS) put in
-how much urine (its characteristics as well) pulled out upon
insertion
-bag on stationary piece
-bed low
-call light on and near
Catheter discontinuation documentation: Correct Answer -size
-how much water put in and how much fluid pulled out
-told patient to drink water
-teach when they void to notify nurse
-bag placed at bed
-bed low
-call light on and near
---must try to get all fluid initially put in out
-i.e if only 7 mL pulled instead of 10mL, document you tried to
get all out but that the catheter came out smoothly
Catheter female problem shooting: Correct Answer Wrong
orifice?
leave in, grab new kit, start over
-never reinsert that same Cath into new spot- spreads bacteria
, -this method also helps find correct placement
Patient is moving legs
-ask to be as still as possible
-get help to support legs
-if field is contaminated, must start over
Urine flow is now decreased
-check tube for kinks or blockages
-sediments, sitting on tube can be issues
Severe pain with balloon inflation
-stop
-withdraw fluid
-advance catheter further
-inflate balloon slowly
Urine leak around catheter
-consider balloon not inflated completely, UTI, constipation
-labor contractions and babies can cause leaks
Catheter problem shooting in male? Correct Answer Pain with
ballon inflation
-stop
-withdraw fluid
-advance catheter further
-inflate balloon slowly
If you can't insert past 3-4 inches and rotate, take deep breaths,
call MD if this doesn't work
May need a coude
Complete Solutions
A sterile catheter kit contains: Correct Answer -sterile gloves
-sterile drapes
-sterile catheter
-antiseptic cleaner (betadine or chlorohexidine)
-cotton balls
-antiseptic swabs
-lube
-forceps
-prefilled syringe with sterile water (10cc or whatever is the
balloons holding capacity)
-sterile basin
-sterile specimen container
-leg securement device
Care for the catheter patient Correct Answer -handwashing
-correct insertion with sterility
-female- thigh securement
-male abdomen securement (avoid tugging on urethra, more
comfortable and decreased infection risk)
-drainage bag below bladder to prevent back flow
-tube and bag off ground and on stationary object
-keep closed until open for emptying and irrigation
-urine specimens collected by aseptic and closed method
-keep free from obstruction
-avoid irrigating unless MD ordered or to remove obstruction
-adequate fluid intake
-empty bag at 1/2 to 2/3 full
-don't touch spout of bag to collection device
,-clean bag and provide peri care daily
-strict I&O followed
Cather insertion documentation: Correct Answer -date
-time
-size of cath
-patient response
-sterile technique used!
-how much water (Not NS) put in
-how much urine (its characteristics as well) pulled out upon
insertion
-bag on stationary piece
-bed low
-call light on and near
Catheter discontinuation documentation: Correct Answer -size
-how much water put in and how much fluid pulled out
-told patient to drink water
-teach when they void to notify nurse
-bag placed at bed
-bed low
-call light on and near
---must try to get all fluid initially put in out
-i.e if only 7 mL pulled instead of 10mL, document you tried to
get all out but that the catheter came out smoothly
Catheter female problem shooting: Correct Answer Wrong
orifice?
leave in, grab new kit, start over
-never reinsert that same Cath into new spot- spreads bacteria
, -this method also helps find correct placement
Patient is moving legs
-ask to be as still as possible
-get help to support legs
-if field is contaminated, must start over
Urine flow is now decreased
-check tube for kinks or blockages
-sediments, sitting on tube can be issues
Severe pain with balloon inflation
-stop
-withdraw fluid
-advance catheter further
-inflate balloon slowly
Urine leak around catheter
-consider balloon not inflated completely, UTI, constipation
-labor contractions and babies can cause leaks
Catheter problem shooting in male? Correct Answer Pain with
ballon inflation
-stop
-withdraw fluid
-advance catheter further
-inflate balloon slowly
If you can't insert past 3-4 inches and rotate, take deep breaths,
call MD if this doesn't work
May need a coude
