Fundamentals of Nursing 9th Edition – Lessons 1–5 Post Tests & Urinary Catheterization Answer Key (NUR101)

Fundamentals of Nursing 9th Edition – Lessons 1–5 Post Tests & Urinary Catheterization Answer Key (NUR101) Lesson 1 Post Test 1. During the change-of-shift report the nurse states that a patient has early renal failure and that you should be alert to this when administering medications. Why would this be a concern? a) The kidneys assist in the detoxification of drug metabolites. b) The patient may not be able to absorb all of the medications. c) The bladder acts as a filter to remove wastes and form urine. d) The kidneys are the primary site for drug metabolism. Correct answer: a Rationale: The kidneys detoxify and eliminate by products of drug metabolism. If the kidneys are unable to perform this function, drug toxicity can develop. The nephron, the functional unit of the kidney, forms the urine. The bladder holds the urine until it is excreted. The liver is a primary site for drug metabolism. 2. Which of the following demonstrate that further teaching is required to prevent an infection related to being catheterized? (Select all that apply.) a) An elderly female carries her urinary drainage bag like a purse under her arm as she ambulates. b) A patient drinks an entire pitcher of water over the period of one day. c) As a patient is being transferred in a wheelchair, he places the drainage bag in his lap. d) The NAP places a patient’s drainage bag on a lowered side rail or on the floor. e) A female patient keeps her catheter secured to her thigh with tape. Correct answer: a, c, d Rationale: The urinary drainage bag should be kept below the level of the bladder to prevent reflux of urine into the bladder. Patients should be instructed to carry the drainage bag below the level of the bladde, and to secure the drainage bag to the side of the wheelchair below the level of the bladder during transfer. The urinary drainage bag should never be placed on a bedside rail because it could accidentally be raised to a height higher than the level of the bladder and urine could reflux into the bladder. The urinary drainage bag should never be placed on the floor; this is to avoid having bacteria enter the system through the drainage port. If allowed, fluids should be encouraged. The catheter should be secured to the patient in order to prevent trauma to the urethra. Swelling of tissues can impair urine flow and place the patient at further risk for urinary tract infection. 3. Which of the following is (are) true regarding the impact of aging related to urinary elimination? (Select all that apply.) a) The elderly are better able to concentrate urine than the middle-aged adult. b) Aging can affect continence if the patient experiences impaired mobility or decreased muscle tone. c) The elderly are less likely to experience urinary frequency than middle-aged adults because they tend to drink less. d) The elderly are at increased risk for urinary tract infection (UTI) because of retained urine in the bladder. Correct answer: b, d Rationale: The very young and very old are less able to concentrate urine, thereby placing them at risk for dehydration. The elderly are at an increased risk of urinary incontinence if they have impaired mobility that prevents them from getting to the bathroom in time or from manipulating buttons and zippers. Weak abdominal and pelvic floor muscles impair bladder contraction. Decreased muscle tone increases the risk for urinary incontinence. Urination frequency increases with age with decreased bladder tone. Because the bladder cannot contract as effectively, an older person often retains urine in the bladder after voiding (residual urine). This places the patient at increased risk for bacterial growth and the development of UTIs. 4. The nursing instructor is reviewing the renal system and urinary catheterization with students. Which statement, if made by a nursing student, indicates that further instruction is needed? a) “The urinary tract is considered sterile.” b) “The nurse may use clean technique to insert an indwelling catheter.” c) “The urge to void is felt when the bladder contains 150 to 200 mL in an adult.” d) “The minimum average hourly urine output is 30 mL.” Correct answer: b Rationale: Sterile technique is used whether inserting a straight or indwelling urinary catheter. Patients may use clean insertion technique in the home setting for intermittent catheterization. When the patient is in an acute or long-term care setting, sterile insertion technique is required because of the high risk for nosocomial infections. The urinary tract is sterile. The desire to urinate can be sensed when the bladder contains a smaller amount of urine (150 to 200 mL in an adult; 50 to 100 mL in a child). The minimum average hourly output is 30 mL. 5. A 53-year-old patient is being treated for hypertension and a history of thrombophlebitis (blood clots). She comes to the clinic complaining, “I have to get up all night to go to the bathroom, and I think my urine looks orange!” What is your best response? a) “It sounds like you may have a urinary tract infection.” b) “Your high blood pressure is adversely affecting your kidneys.” c) “How much fluid are you drinking in a day?” d) “What medications are you taking and when?” Correct answer: d Rationale: You should first assess the patient’s medication history before making any interpretation. The patient may be taking diuretics before going to bed or taking other medications that can change the urine’s color. 6. A 68-year-old female patient is admitted for knee-replacement surgery with an expected hospital stay of 2 weeks. She has no known allergies. The physician has ordered an indwelling Foley catheter to be inserted preoperatively. Which catheter should you choose? a) 14 French, 5-mL balloon, latex catheter b) Coude catheter c) 16 French plastic catheter d) 18 French, 5-mL balloon, latex catheter e) 8 French, 3-mL balloon, latex catheter f) 16 French, 30-mL balloon, silicon catheter Correct answer: a Rationale: Women require a 14 to 16 French catheter; it is usually best to begin with the smaller size. A 5-mL balloon is a common size balloon. Latex and rubber catheters are recommended for use up to 3 weeks. A Coudé (elbowed and/or curved) catheter is often used for males with prostatic hypertrophy. Plastic catheters are suitable only for intermittent use because of their inflexibility. Men require a 16 to 18 French catheter; this would be too large for this patient. Pure silicon or Teflon catheters are best suited for long-term use (2 to 3 months). The 8- French, 3-mL balloon, latex catheter is a pediatric catheter. Lesson 2 Post Test 1. A nurse is explaining the procedure for inserting an indwelling urinary catheter. Which of the following explanations regarding anchoring the catheter would be most accurate? a) An indwelling catheter tube is secured to a female patient’s abdomen to prevent accidental dislodgment. b) An indwelling catheter tube is secured to the male’s inner thigh with a strip of nonallergenic tape or a commercial tube holder. c) It is important to anchor the catheter tubing in order to minimize the risk for urethral trauma, minimize bladder spasms from traction, and prevent accidental dislodgment. d) When securing the catheter tubing, slack in the catheter should be avoided to prevent movement and possible tissue injury. Correct answer: c Rationale: Securing the catheter will minimize the accidental dislodgment of the catheter. It also minimizes the risk for bleeding, trauma, meatal necrosis, and bladder spasms from pressure and traction. Male patient catheter tubes are attached to the lower abdomen or to top of the thigh; female patient tubes are attached to the inner thigh. Allow slack in catheter so that movement does not create tension on the catheter. 2. The nursing assistive personnel (NAP) reports leakage around a patient’s urinary catheter. What action should the nurse take first? a) Attempt to reinflate the balloon. b) Increase the patient’s fluid intake, and reassess in 1 hour. c) Remove the catheter and replace with a smaller size. d) Obtain a urine specimen. Correct answer: a Rationale: Leakage around the urinary catheter could indicate that the catheter inserted was too small or that the balloon failed. The nurse should attempt to reinflate the balloon and, if this does not work, then replace the catheter. Increasing the patient’s fluid intake would not improve a leaking catheter. If the patient had a low hourly urine output, this may be appropriate. If the cause is not a faulty balloon, the nurse may need to contact the physician in order to get an order for a larger catheter. The patient is not exhibiting symptoms of infection, so there is no need for an order for any laboratory testing of a urine sample. 3. The nurse has been called to make a home visit to a patient with a history of a spinal cord injury and an indwelling Foley catheter. The patient appears diaphoretic and his face is flushed. The nurse takes the patient’s vital signs with the following results: Temperature 98.4° F, pulse 54, respirations 20, and blood pressure 160/100. The patient’s head of the bed is elevated. What action should the nurse take next? a) Notify the physician. b) Check for any kinks in catheter tubing. c) Have the patient take slow deep breaths. d) Lower the head of the bed. Correct answer: b Rationale: Autonomic dysreflexia is a medical emergency caused by bladder (or bowel) distention after spinal cord injury. The first action should be to assess for bladder fullness and drain the patient’s bladder (i.e., empty bladder by removing any blockage and/or kinks in the catheter tubing). The patient’s head should be elevated. If this does not resolve the patient’s symptoms, the nurse may consult with the physician. 4. The nursing assistive personnel (NAP) is helping the nurse insert a Foley catheter on a male patient. In which position should the NAP place the patient? a) Sim’s position b) Dorsal recumbent c) Supine with legs adducted d) Supine with legs slightly abducted Correct answer: d Rationale: Sim’s position would be appropriate for a female patient with mobility limitations or for a male who cannot lie flat. The dorsal recumbent position would be appropriate for catheterizing a female patient. Legs adducted means that the patient’s legs are together. The appropriate position for catheterizing a male patient is supine with the legs slightly abducted. 5. Which of the following actions associated with Foley catheterization could cause a potential problem? a) Keeping the bedside drainage bag attached to the bed frame. b) Keeping the foreskin retracted after catheterization. c) Failing to test the balloon by injecting fluid from prefilled sterile water syringe into the balloon port prior to insertion. d) Cleansing the far labial fold, the near labial fold, and directly over the center of urethral meatus using a new swab with each area. Correct answer: b Rationale: Failure to reduce the foreskin after catheterization can result in paraphimosis (constriction of the foreskin). The bedside drainage bag should be attached to the bed frame and not the bed rails to avoid accidentally raising the rails (and the collection bag) above the level of the bladder allowing reflux of urine. Testing the balloon by injecting fluid from the prefilled sterile water syringe into the balloon port is no longer a common practice. Testing the balloon may stretch the balloon and lead to damage causing increased trauma on insertion. Cleansing the far labial fold, the near labial fold, and directly over the center of urethral meatus using a new swab with each area is the correct procedure for cleaning the female patient. 6. A 40-year-old male patient has been admitted for abdominal surgery. He has no history of prostate problems. The physician has ordered that the patient be catheterized. Which of the following would be an appropriate size catheter for this patient? a) 8 French, 3-mL balloon b) 14 French, 5-mL balloon c) 16 French, 5-mL balloon d) 16 French, 30-mL balloon Correct answer: c Rationale: The 16 French, 5-mL balloon is an appropriate catheter for an adult male who has never had prostate surgery. The 8 French, 3-mL balloon is a pediatric-size urinary catheter. The 14 French, 5-mL balloon is an appropriate-size catheter for an adult female. The 16 French, 30- mL balloon is an appropriate-size catheter for an adult male who had prostate surgery. 7. As part of catheter insertion assessment, where should you palpate? a) At the costovertebral angle b) Above the symphysis pubis c) Starting at the right iliac crest and moving upward along the midclavicular line d) Midway between the xyphoid process and symphysis pubis Correct answer: b Rationale: When empty, the bladder is difficult to locate and palpate; if it is full, it may be palpated as a dome-shaped structure above the symphysis pubis. If the bladder is severely distended, it may extend into the abdomen. The costovertebral angle is formed by the last rib and vertebral column and is a landmark used during kidney palpation. Palpating the kidneys is unrelated to bladder fullness. The nurse may use percussion starting at the right iliac crest and move upward along the miclavicular line in order to determine the size of the liver. Liver size is unrelated to bladder fullness. The area of the umbilicus is located between the xyphoid process and sumphysis pubis. 8. You are inserting an indwelling Foley catheter in a male patient. You have asked the patient to bear down as if to void, and you slowly insert the catheter through the urethral meatus. You advance the catheter and meet resistance. What is your best initial action at this time? a) Ask the patient to take slow deep breaths while you insert the catheter slowly. b) Withdraw the catheter and notify the physician. c) Apply more force to insert the catheter inward. d) Remove the catheter, apply more lubricant, and reinsert. Correct answer: a Rationale: If there is resistance to catheter insertion, have the patient take slow, deep breaths to promote relaxation while you insert the catheter slowly. Another the technique is to rest your arm against the patient’s leg and ask him to relax. When the leg muscles begin to relax, continue the insertion process. If there is persistent resistance to insertion, the patient may have an enlarged prostate. Then, it is appropriate to notify the prescriber; a coudé catheter, with a slightly curved end, may be needed to facilitate insertion. 9. Match the unexpected outcome with the probable cause. Correct match: Enlarged prostate Unable to advance catheter into bladder Spasm, bladder infection, or injury to the urinary tract After catheter insertion and urine return, patient continues complaining of discomfort Catheter in the urethra but outside the bladder, or catheter in the vagina rather than in the urethra Lack of urine Rationale: Lack of urine may be due to the bladder being empty, to renal failure, or to urinary tract obstruction. A common cause is that the catheter is misplaced; that is, the catheter is in the urethra but outside of the bladder, or the catheter is in the vagina rather than in the urethra. Inability to advance the catheter is caused by urethral obstruction such as an enlarged prostate in the male patient. Bladder discomfort may be caused by spasm, infection, or injury to the urinary tract. 10. You have a sterile urinary catheter and sterile gloves. Choose the remaining equipment you will need to insert a straight urethral catheter: (Select all that apply.) a) Sterile cotton balls b) Antiseptic solution c) Sterile urinary collection bag d) Water-soluble lubricant e) Clean cotton balls f) Sterile forceps g) Sterile water in a syringe (without needle) Correct answer: a, b, d, f Rationale: Straight urinary catheterization requires aseptic (sterile) technique. You will need five to six sterile cotton balls soaked in antiseptic solution, such as Betadine, to reduce the number of microorganisms present on perineal area. Sterile forceps are used to pick up the antiseptic- saturated cotton balls. Water-soluble lubricant is used to ease insertion of the catheter. Once the cather is inserted, you will need a container to catch the urine. If you require a urinary specimen, you will need a sterile specimen cup. If you are catheterizing to empty the bladder, you may use a bedpan. A sterile urinary collection bag is used for an indwelling catheter. Sterile water or normal saline in a syringe is used to inflate the balloon on an indwelling catheter and is unnecessary for a straight catheter. 11. Identify the reasons why a patient with an indwelling catheter may have less than 30 mL per hour of urine in the collection bag: (Select all that apply.) a) The catheter has slipped out of the bladder. b) The patient is severely dehydrated. c) The patient’s kidneys are damaged or injured. d) The patient has a UTI. Correct answer: a, b, c Rationale: If the catheter is in the urethra outside the bladder, it cannot drain urine. If the patient has insufficient fluid intake, urinary output will be reduced. A sign of renal failure is urine output of less than 30 mL per hour. A UTI rarely results in urinary output of less than 30 mL per hour. 12. Reasons for lack of urine after inserting a straight catheter include which of the following? (Select all that apply.) a) The catheter is outside of the bladder. b) The catheter is inserted in the vagina rather than in the urethra of a female patient. c) The male patient’s prostate is preventing urine from exiting the bladder. d) Urethral spasms are preventing urine from exiting the body. Correct answer: a, b Rationale: The catheter may be in the urethra ahead of the internal sphincter of the bladder. Catheter malposition may be a cause of lack of urine. Urethral spasms may cause discomfort but will not prevent urine flow with an established catheter. An enlarged prostate may hinder catheter insertion but once inserted, does not prevent urine from exiting the body. 13. A nursing student is watching a nurse catheterize a female patient with an indwelling catheter. Which of the following, if it occurs, indicates a break in sterile technique? (Select all that apply.) a) The nurse inserts the urinary catheter, and when urine does not return, the nurse removes the catheter and makes a second attempt to locate the urethra with the same catheter. b) The nurse lubricates the catheter and places it back into the sterile tray when it uncoils and touches the bed. c) After the nurse cleans the labia, the labia become slippery and closes as the nurse attempts to obtain a clear view of the urethra. d) The nurse advances the catheter another 2.5 to 5 cm (1 to 2 inches) after urine appears, releases the labia, and holds onto the catheter with the nondominant hand. e) The nurse uses forceps and a new cotton ball when cleansing the area, wiping along the far labial fold, the near labial fold, and directly over the center of the urethral meatus. Correct answer: a, b, c Rationale: You should never use the same catheter to attempt an insertion a second time because the catheter is contaminated. You should leave the first catheter in the vagina as a landmark and insert another sterile catheter. If the catheter touches the bed, you should obtain a new sterile catheter because the first one has become contaminated. If closure of the labia occurs during cleansing, the cleansing procedure should be repeated because the area has become contaminated. Once urine appears, you should advance the catheter to ensure bladder placement. The nurse is correct in releasing the labia and holding onto the catheter with the nondominant hand, because bladder or sphincter contraction may cause accidental expulsion of the catheter. The dominant hand is used to inflate the balloon of the catheter. The nurse also used the correct technique in cleansing the area. 14. A nurse is inserting a catheter in a female patient advances the catheter and obtains clear, yellow urine. What is the next action the nurse should take? a) Inflate the balloon with the prefilled syringe of sterile water in the balloon port. b) Pull gently back on the catheter approximately 1 inch or until resistance is met. c) Advance catheter another 1 to 2 inches and inflate balloon. d) Ask the patient to bear down as if to void. Correct answer: c Rationale: The female urethra is short. Appearance of urine indicates that catheter tip is in bladder. Advancement of catheter ensures that the inflation balloon is in the bladder and not the urethra. The nurse pulls back gently on the catheter after the balloon is inflated. The nurse may ask the patient to bear down as if to void when initially inserting the catheter—this maneuver relaxes the external urethral sphincter. 15. The nurse has inserted a catheter 7.5 cm in a female patient and obtains no urine return even though her bladder is distended. What action should the nurse take at this time? a) Remove the catheter and have another nurse attempt to catheterize the patient. b) Leave the catheter in vagina as a landmark and insert another sterile catheter. c) Remove the catheter and reinsert into the urethra. The nurse may straighten the urethra by inserting one finger of a sterile, gloved hand inside the vagina and applying gentle pressure upward. d) Inflate the balloon and reassess in 1 hour for urine return in the bedside drainage bag. Correct answer: b Rationale: There should be a urine return since the patient’s bladder is distended. If no urine appears, the catheter may be in the vagina. If misplaced, the nurse should leave the catheter in vagina as a landmark where not to insert, and insert another sterile catheter. The nurse may straighten the urethra by inserting one finger of a sterile, gloved hand inside the vagina and applying gentle pressure upward, however a new sterile catheter should be used. 16. The nurse is catheterizing a male patient and obtains a clear amber urine return. As the nurse begins to inflate the balloon, the patient complains of pain and resistance is felt. What is the nurse’s best action? a) Allow fluid to flow back into syringe, and advance the catheter a little more before attempting to reinflate. b) Have the patient take slow, deep breaths by inhaling through the nose and exhaling through the mouth. c) Lift the penis to a position perpendicular to patient’s body, and apply light traction. d) Advance catheter to bifurcation of the drainage and balloon inflation port. Correct answer: a Rationale: If resistance occurs when inflating the balloon or the patient verbalizes or shows nonverbal signs of pain, the balloon may not be entirely within the bladder. Stop inflation; allow fluid to flow back into the syringe, and advance the catheter a little more before reattempting to inflate. Having the patient take slow, deep breaths may help the patient relax but does not help with resistence or pain. Lifting the penis to a perpendicular position and applying light traction is done to straighten the urethra. Advancement of the catheter to bifurcation of the drainage and balloon inflation port ensures proper placement of catheter through the longer urethra of the male patient. Lesson 3 Post Test 1. Which of the following would be inappropriate to delegate to NAP? a) Application of a condom catheter b) Perineal care c) Emptying a leg bag and recording on an I&O record d) Foley catheter insertion Correct answer: d Rationale: Insertion of a Foley catheter requires the skill of the nurse and should not be delegated to an NAP. The NAP may apply a condom catheter, perform perineal care, or empty a leg bag and record the amount of fluid on the I&O report. 2. Which of the following could be considered negligence? a) A condom catheter is removed every 3 days. b) Clean gloves are worn to apply a condom catheter. c) Allow a family caregiver to apply the condom catheter. d) Avoiding the use of barrier creams on the penile shaft. Correct answer: a Rationale: The condom catheter should be removed and perineal care performed at least every 24 hours in order to prevent skin breakdown and/or infection. Applying a condom catheter does not require sterile technique. Clean gloves should be worn to prevent the transmission of microorganisms. The use of barrier creams should be avoided because they prevent the sheath from adhering to the penile shaft. Skin protectant may be used if prescribed. 3. During application of the condom catheter, the adhesive strip falls to the floor. What is the nurse’s best action? a) Obtain silk tape because it has some ability to stretch. b) Use paper tape in a spiral fashion because it is nonallergenic. c) Use plastic IV tape because it is waterproof, which prevents slippage. d) Obtain another adhesive strip from condom catheter kit. Correct answer: d Rationale: Only the adhesive strip that comes with the catheter should be used. Other tapes are unable to provide the flexibility needed for spiral wrap and may impair circulation of the penis. 4. The nurse is assessing the patient’s condom catheter. Which of the following most likely indicates the that condom catheter should be removed? a) Patient complains of the leg bag feeling “heavy” while in bed b) Redness and/or excoriation of the penis c) Patient’s urine appears clear amber with ammonia smell d) Less than 30 mL/hr of urinary output. Correct answer: b Rationale: Redness and excoriation of the penis are both signs of impaired skin integrity. If the patient complains that the leg bag feels heavy while in bed, he may need to be changed to a bedside drainage bag while lying down. Normal urine appears clear amber and has an ammonia smell. If the hourly urinary output appears low, the catheter should be checked for twisting or kinks first. This does not necessarily mean that the catheter must be removed. 5. The NAP is applying a condom catheter to the patient. The patient asks, “What is the purpose of the skin preparation solution?” The NAP correctly responds: a) ”It is used before condom sheath application as an adhesive to hold the condom catheter on.” b) “It is an antiseptic to clean pathogens from the area before applying the condom catheter.” c) “The skin preparation solution prevents skin irritation and should be dry before the condom catheter is applied.” d) “The skin preparation solution helps the condom catheter to go on more easily, which reduces friction,and should still be wet when the sheath is applied.” Correct answer: c Rationale: The skin preparation solution prevents skin irritation and should be dry before the condom catheter is applied 6. You are teaching the male patient and family caregiver about the advantages of a condom catheter. Which of the following would you include in the teaching? (Select all that apply.) a) It is relatively safe and noninvasive. b) It ensures complete bladder emptying. c) It is a convenient method of draining urine. d) It is used for male patients who are incontinent. e) It may remain in place for several days to a week, if it remains intact. f) It carries less risk of developing a UTI than an indwelling catheter. Correct answer: a, c, d, f Rationale: The external application of a condom catheter is a convenient, safe method of draining urine in male patients. There is less risk of the patient developing a UTI because it is noninvasive. It is suitable for incontinent or comatose patients who still have complete and spontaneous bladder emptying. Unlike a straight or indwelling catheter, the condom catheter cannot ensure complete bladder emptying, because it only provides a means for draining the urine that is spontaneously expelled from the body. It should be changed every 24 hours, even if it is intact, but can be replaced. 7. The nurse is caring for a patient who is unable to get out of bed. During the nurse’s routine assessment, the nurse notices that urine seems to be pooling in the space at the end and around the condom catheter. The NAP comes to you complaining that the patient’s condom catheter has fallen off for the second time today, requiring changing of bed linens. Which is an appropriate response from the nurse? a) “Just leave the condom catheter off because it doesn’t seem to be working. I’ll see if the doctor will order a Foley catheter.” b) “I will contact the physician to see if the patient’s IV fluids can be decreased so that he won’t be voiding so often.” c) “You can add some additional tape at the base of the patient’s penis in order to hold it in place better.” d) “Please apply a new condom catheter, but this time, don’t leave any space between the tip of the penis and the end of the condom catheter.” e) “Let’s change the patient from a leg bag to a bedside drainage bag and see if that helps.” f) “Let’s check the condom catheter size. Perhaps there is one that will fit better.” Correct answer: f Rationale: If the condom falls off, the nurse should reassess the current condom size, check the manufacturer’s size chart, and reapply as necessary. Perineal hygiene should be provided before application of the condom catheter. The patient’s fluids should never be limited to decrease urine output. Avoid adding additional tape or overlapping tape, because it may impede circulation. Only the tape that is provided by the manufacturer should be used. Space should be left between the glans penis and the condom catheter to allow free flow of urine and avoid irritation of the glans penis. Foley bags are better for the bedridden patient, because they have less risk of impairing venous circulation of the leg than a leg bag. Lesson 4 Post Test 1. Obtaining a urine sample from an indwelling catheter requires sterile technique. True / False Correct answer: True Rationale: Sterile technique is used to prevent contamination of the sterile specimen and to avoid introducing microorganisms into a closed urinary system, which could cause a UTI. 2. After a patient has had a Foley catheter for 1 week, a urine specimen may be obtained from the bedside drainage bag. True / False . Correct answer: False Rationale: A urine specimen may be obtained through an indwelling catheter only at the time of catheter insertion, before it is connected to the bedside drainage bag. . 3. Obtaining a sterile urine sample for testing by using a straight catheter can be delegated to an NAP. True / False Correct answer: False Rationale: This procedure is inappropriate to delegate to NAP. 4. You are to collect a sterile urine specimen for culture and sensitivity from your patient’s indwelling Foley catheter. Choose the supplies that you will need to carry out the procedure. (Select all that apply.) a) Sterile gloves b) Clean gloves c) Alcohol or disinfectant swab d) 5-mL Luer-Lok syringe e) 20-mL Luer-Lok syringe f) Catheter clamp or elastic band g) Sterile specimen container h) Completed laboratory requisition i) Completed identification label j) Towel and/or protective barrier k) Bedpan l) Soap, water, washcloth, and towel m) Sterile cotton balls Correct answer: b, c, d, f, g, h, i Rationale: The supplies you will need to collect a sterile urine specimen for culture and sensitivity include the following: clean gloves, an alcohol swab, a 5-mL Luer-Lok syringe to be attached to needle free port, a catheter clamp or elastic band, a sterile specimen container, a completed laboratory requisition, and an identification label. Although aseptic technique is followed, sterile gloves are unnecessary since you are using a sterile syringe and needle to obtain the urine. The gloves are for personal protection from exposure to body fluids. A 20-mL syringe is used for routine urine studies. A towel and/or protective barrier, bedpan, soap, water, washcloth, towel, and sterile cotton balls are unnecessary for collecting a sterile urine specimen the test.” c) “After you clamp my tubing, I’m probably going to need some pain medication.” d) “It won’t hurt me when you get the urine.” e) “The doctor is checking to see if I have a UTI.” f) “You will have to insert a new catheter to get a sterile specimen.” Correct answer: a, b, c, f Rationale: The urine specimen will be obtained from the sampling port of the urinary catheter system. The only time urine may be collected from the drainage bag is immediately after insertion. The urinary drainage system should remain closed to avoid the introduction of microorganisms that could ascend and cause a subsequent UTI. The patient may feel some pressure as the bladder fills with urine, but pain is unexpected. The syringe is attached to the needle-free sampling port in order to obtain the urine sample rather than into the patient’s body. Changing the catheter is unnecessary to obtain a sterile urine specimen. A sterile urine specimen for culture and sensitivity is used to determine the presence of infection and antibiotics that will be effective against the pathogenic organism. 6. What is the recommended amount of time to leave the catheter clamped when obtaining a urine specimen from an indwelling catheter? a) 15 minutes b) 1 hour c) 2 hours d) 30 minutes Correct answer: d Rationale: The recommended amount of time to leave the catheter clamped when obtaining a urine specimen from an indwelling catheter is 30 minutes. This allows time for urine to accumulate for collection without causing bladder distention. 7. Sequence the following steps for collecting a urine sample from an indwelling catheter. Correct sequence: a) Insert a 21-gauge, 1-inch needle attached to a 3- or 20-mL syringe into the center of the samplin Third b) Transfer the urine to the appropriate container. Place the lid on the container. Unclamp the catheter. Discard the gloves and used supplies, perform hand hygiene, attach the identification label to the container and complete the requisition, and send the sample to the laboratory in a biohazard bag. Last c) Document the collection of the specimen. First d) Clamp the drainage tubing below the sampling port of the catheter for 30 minutes. Apply gloves, cleanse the sampling port with a disinfectant swab, and allow it to dry. Rationale: The drainage tubing should be clamped with an elastic band or catheter clamp for 30 minutes below the catheter sampling port. After the 30 minutes have elapsed, apply clean disposable gloves and wipe the sampling port with a disinfectant swab. Allow it to dry. Next, insert a 21-gauge, 1-inch needle attached to a 3-mL or 20-mL syringe into the center of the sampling port or attach a 3- or 20- mL leurlok syringe to the needleless sampling port. Draw 3 mL into a syringe for a urine culture or 20 mL for routine urine studies. Transfer the urine to a sterile specimen cup for a urine culture and into a clean container for routine urine studies. Place the lid on the container. Remove the clamp from the drainage tubing. Discard the gloves and used supplies; perform hand hygiene. Attach the identification label to the container and complete the requisition. Send the specimen in a biohazard bag along with the requisition immediately to the laboratory. Document the collection of the specimen. 8. When obtaining a sterile urinary catheter specimen, the sterile specimen container should be opened and the lid: a) Placed with the inside up b) Placed with the inside down c) Held, because setting it on a table without a draped surface will cause contamination d) Loosened but left on the container Correct answer: a Rationale: The sterile inside of the cap should be facing up to avoid contamination. It would be difficult to manipulate and obtain the midstream urine specimen if the lid were still on. 9. Which of the following actions, if made by the nurse, could be considered negligence? a) Leaving the drainage tubing below the catheter port clamped for 30 minutes b) Using aseptic technique to obtain 5 mL of urine for a urine culture c) Obtaining the urine specimen at 1030 and transporting it to the laboratory at 1115 d) Labeling the cup but not the lid and transporting the specimen in a biohazard bag Correct answer: c Rationale: Bacteria can multiply rapidly at room temperature. The specimen should be sent to the laboratory within 20 minutes or refrigerated for up to 2 hours. It is appropriate to clamp the drainage tubing below the catheter port for 30 minutes in order for urine to accumulate for collection. Aseptic technique should be used to prevent contamination of the specimen. At least 3 mL of urine is necessary to perform a urine culture. The cup should be labeled, not the lid to prevent errors related to incorrect identification. Lesson 5 Post Test 1. The nurse is reviewing urinary catheter care with a newly hired nursing assistive personnel (NAP). Which statement made by the NAP indicates that further instruction is needed? a) “Urinary catheter care is a clean procedure; sterile gloves are an unnecessary expense.” b) “The bedside drainage bag should only be emptied when it is full.” c) “During catheter care, you should replace as necessary and relocate the tape that anchors the catheter.” d) “Condom catheter care can be delegated to NAP and family members.” Correct answer: b Rationale: The fluid collection bag should be emptied when two-thirds full, or at least once every 8 hours. Clean technique is used to perform catheter care and sterile gloves are unnecessary. Moving the tape prevents the skin from becoming irritated. After reviewing the signs of infection, characteristics of normal urine, and the proper procedure, this task can be delegated to NAP and/or family members. 2. The NAP documents “Peri-care given” next to “Urinary Catheter” on a patient with an indwelling urinary catheter. What is the best explanation of what the NAP did after application of clean gloves? a) The NAP washed the perineal area with soap and water and applied a topical antimicrobial ointment at the urethral meatus around the catheter. b) The NAP stabilized the catheter and washed the catheter with soap and water from where the catheter enters the meatus down 4 inches toward the drainage tubing. c) The NAP inserted the hub of syringe into balloon port, thus allowing the sterile water to return passively into the syringe and slid the catheter out into a waterproof pad. d) The NAP obtained a squirt bottle of warm water and had the patient squirt it over their perineum while sitting on the toilet. Correct answer: b Rationale: After routine perineal care is given with soap and water, the catheter is cleansed. While stabilizing catheter with dominant hand and using a clean washcloth, soap, and water, the catheter is cleaned in a circular motion along its length for about 10 cm (4 inches). Cleansing starts where the catheter enters the meatus and down toward the drainage tubing. The application of topical anticrobial products is not effective in reducing meatal bacterial flora and reducing risk for UTI. Do not include them as a part of routine catheter care. 3. Which of the following indicates a reason for notifying the prescriber to get an order for removal of an indwelling catheter? a) The patient states, “My bladder feels so full, it is starting to hurt!” b) The catheter has been in place for 3 days. c) The patient’s urine appears cloudy with a foul odor. d) The patient is drinking less than 1500 mL of fluids daily. Correct answer: c Rationale: These are symptoms of a UTI. A UTI may be cause for an indwelling catheter to be removed. The physician should be notified as a sterile urine specimen may be ordered prior to removing the catheter. An indwelling catheter should be removed as soon as possible after insertion because of the risk for catheter-associated urinary tract infection (CAUTI). If the patient states that his bladder feels very full and is starting to hurt, it may indicate that the tubing is kinked or that the patient may be lying on the tubing, thereby preventing drainage. How long a catheter remains in place is determined by several factors, such as the type of material the catheter is made of, agency policy, reason for the catheter, and whether the patient is experiencing any complications. Often catheters intended for long-term use are changed once a month. Patients who are not drinking sufficient amounts of fluid should be encouraged to drink more. Remember to count IV solution in the fluid intake calculation. 4. A patient had an indwelling catheter for 3 weeks. The patient had the catheter removed 3 hours ago and now complains of needing to go to the bathroom frequently and that it is painful to void. Which instruction is appropriate for you to give the patient? a) “This is a normal occurrence after having a catheter in place for more than several days.” b) “It sounds like you have a UTI. I will notify your physician.” c) “I will need to inspect your perineal area and wash and dry the area.” d) “If these symptoms continue, I will notify your physician to see if we can reinsert the catheter.” Correct answer: a Rationale: If the catheter was in place for more than several days, the patient may experience dysuria (i.e., painful voiding) resulting from inflammation of the urethral canal. As a result of decreased bladder muscle tone, the patient may urinate frequently. These symptoms should subside with time. 5. If a patient’s indwelling catheter is removed at 0900, the patient should be due to void by: a) 1900 to 2100 (7 PM to 9 PM) b) 1100 to 1200 (11 AM to 12 PM) c) 1500 to 1700 (3 PM to 5 PM) d) 0930 (9:30 AM) Correct answer: c Rationale: The patient should be due to void in 6 to 8 hours or by 3PM to 5 PM. If the patient fails to void, nursing measures should be taken (i.e., assess for bladder fullness, provide privacy, assist to normal voiding position, run water). If unsuccessful, the physician should be notified. 6. Identify the indicators of a UTI. (Select all that apply.) a) Cool and clammy skin b) Fever c) Urinary drainage d) Complaints of pain e) Hypothermia f) A feeling of bladder fullness g) Abdominal pressure and discomfort h) Cloudiness of the urine Correct answer: b, d, g, h Rationale: Fever is an indication of infection. Complaints of pain or burning are indicative of a UTI as urine passes over inflamed tissues. The patient may feel abdominal pressure and discomfort with a UTI. Urine should be clear; cloudy urine may indicate the presence of bacteria or white blood cells in the urine. 7. Which of the following steps should you take before removing the fluid from the balloon in a Foley catheter? (Select all that apply.) a) Attach a 2-mL syringe to the balloon port and aspirate the fluid. b) Attach a 10 mL larger syringe to the balloon port and allow the water to passively fill the syringe. c) Attach a 10- or 20-mL syringe to the balloon port and forcibly aspirate the water. d) Cut the balloon port and allow the water to slowly drain into a sterile basin. e) Gently aspirate the syringe plunger if water remains in the balloon. Correct answer: b, e Rationale: A 10-mL or larger syringe should be attached to the balloon port, and the water should be allowed to passively fill the syringe. Gentle aspiration, if necessary, is appropriate. Module Exam 1. A male patient with back and lower abdominal injuries from a motor vehicle accident is unable to void. His physician has requested the insertion of a catheter to determine the amount of residual urine and possibly to assist him with voiding. What type of urinary catheter should the nurse anticipate using? a) A Foley catheter b) A straight catheter c) A coudé catheter d) A condom catheter Correct answer: a Rationale: It is acceptable to use an indwelling catheter in this case to obtain the residual urine amount. This reduces the number of catheterizations to one, especially since the physician has indicated that the patient might need assistance voiding, until the pain subsides. 2. Which of the following requires strict surgical asepsis? (Select all that apply.) a) Inserting a Foley catheter b) Applying a condom catheter c) Performing catheter care d) Emptying a bedside drainage bag Correct answer: a Rationale: Inserting a Foley catheter is an invasive procedure requiring a septic technique. 3. The nurse is catheterizing a male patient. Which of the following demonstrates correct understanding of the procedure? (Select all that apply.) a) The patient is placed in a dorsal recumbent position for urinary catheter insertion. b) The patient is placed in a supine position with legs slightly abducted. c) The nurse cleans the urethral meatus using a circular motion from the meatus down to base of glans. d) The nurse applies sterile gloves before opening the antiseptic solution and lubricant. Correct answer: b, c, d Rationale: Male patients should be placed in a supine position with legs slightly abducted. The nurse then cleans the urethral meatus using a circular motion from meatus down to the base of the glans. This should be repeated 3 times using a clean cotton ball and/or stick each time. Everything in the catheter kit is sterile; therefore, opening the antiseptic solution and lubricant would not contaminate the sterile gloves. 4. The nurse is caring for a Hindu patient. Which of the following would be important nursing measures when inserting a urinary catheter? (Select all that apply.) a) The nurse provides privacy during catheter insertion. b) The nurse is of the same gender as the patient. c) The nurse uses the right hand to handle urinary secretions. d) The nurse avoids putting soiled linens on the bedside table. e) The nurse provides all perineal care for the patient while hospitalized. Correct answer: a, b, d Rationale: This can be an embarrassing procedure for many patients; therefore, privacy should be provided through adequate draping and use of bedside screens. Gender-congruent care for cultures emphasizing separate gender roles and female modesty is important such as African, Hispanic, Asian, Islamic, Arabic, Hindu, Jewish Orthodox, and Amish cultures. The nurse should use the left hand to handle urinary secretions. Hindus and Muslims consider the left hand unclean. The nurse should avoid placing soiled bed linens on top of the bedside table or surface used for praying or eating. The nurse should provide the patient with the equipment and supplies for cleansing after elimination. 5. Identify the procedures that may be delegated to an NAP. (Select all that apply.) a) Insertion of a straight catheter b) Insertion of an indwelling catheter c) Application of a condom catheter d) Collection of a sterile urine specimen from a catheter e) Care of an indwelling catheter Correct answer: c, d, e Rationale: Trained NAP may apply condom catheters, collect sterile urine specimens, and care for an indwelling catheter. 6. Match the clinical situation with the intervention. Correct match: Document the procedure. A 16-French, 5-mL Foley catheter is inserted and well tolerated. The output of 875 mL is clear, yellow urine. The patient is pain free. A urine specimen is sent to the laboratory. gEnsure that the tubing and/or catheter is kink free, then assess the patient for renal failure or for severe dehydration. The urine output from the Foley catheter is less than 30 mL per hour. The patient is due to void between 4:00 and 6:00 PM The Foley catheter is removed at 10 AM Consider whether catheter is too small, the balloon has deflated, or the catheter has slipped out of the bladder. Catheter leaks after insertion. Apply a condom catheter. Patient is an incontinent male who empties his bladder fully. Assess the bladder frequently and monitor the output closely. The patient has a spinal cord injury. Insert a straight catheter. The patient needs a single, sterile urine specimen. Notify the physician. A patient with an indwelling catheter develops a fever; an elevated pulse; lower abdominal pain; and cloudy, foul-smelling urine. Consider prostate enlargement; this may require a Coudé catheter. There is difficulty inserting a catheter with a male patient. Insert an indwelling catheter. Patient is going to have major abdominal surgery. Rationale: A straight catheter may be used when a patient needs a single sterile urine specimen. A patient who is going to have major abdominal surgery requires an indwelling catheter to be inserted before surgery or at the time of surgery. An incontinent male that is able to empty his bladder fully may have a condom catheter applied. If the urine output from a Foley catheter is less than 30 mL per hour, the nurse should ensure that the tubing or catheter is kink free and assess the patient for signs and symptoms of renal failure and/or dehydration. If a patient’s Foley catheter was removed at 10 a.m., the patient would be due to void in 6 to 8 hours or between 4 p.m. and 6 p.m.. A patient with a spinal cord injury should be assessed for bladder fullness frequently, and urine output should be monitored closely to prevent autonomic dysreflexia. Signs and symptoms of a UTI include fever, elevated pulse, lower abdominal pain, and dysuria. The physician should be notified. If you have difficulty inserting a catheter in a male patient, prostate enlargement should be considered; a coudé catheter may be required. If the catheter leaks after insertion, you should consider possible causes such as the size of the catheter being too small, the balloon being deflated, or the catheter having slipped out of the bladder. A correct example of documentation of catheter insertion is: 16 French 5 mL Foley catheter inserted; tolerated well; output of 875 mL clear, yellow urine; pain free; urine specimen sent to laboratory. 7. Match the type of catheter to the type of application. Correct match: Long-term catheterization on a male with an enlarged prostate Figure A Temporary catheterization to obtain a sterile sample from a patient who is unable to void Figure B An incontinent male who is able to void completely 2) Figure C Figure A Figure B Figure C Rationale: The patient who requires long-term catheterization would need a Foley catheter. The patient who requires temporary catheterization to obtain a sterile urine specimen would require a straight catheter. An incontinent male who is able to void completely may be treated with a condom catheter. 8. Match the urinary catheter preparation description to the sex of the patient. Correct match: Male Abduct the patient’s legs during positioning. Gently refract the foreskin, thereby exposing the urinary meatus. Advance the catheter to bifurcation of drainage and balloon port. Lubricate the catheter 12.5 to 17.5 cm (5 to 7 inches). Wipe around the urethral meatus in a circular motion. Lubricate the catheter 12.5 to 17.5 cm (5 to 7 inches) Female Wipe from the clitoris toward the anus. Gently retract the labia and expose the urinary meatus. Lubricate the catheter 2.5 to 5 cm (1 to 2 inches) Advance the catheter 2.5 to 5 cm (1 to 2 inches). Position with the knees flexed and with slight external rotation of the hips. Rationale: The correct urinary catheter procedure description for the female patient is as follows: knees flexed with slight external rotation of the hips, lubricate catheter 2.5 to 5 cm (1 to 2 inches), gently retract the labia and expose the urinary meatus, wipe from the clitoris toward the anus, and advance the catheter 2.5 to 5 cm (1 to 2 inches). The correct urinary catheter procedure description for the male patient is as follows: with legs abducted, gently retract foreskin exposing urinary meatus, wipe around the urethral meatus in a circular motion, lubricate the catheter 12.5 to 17.5 cm (5 to 7 inches), and advance the catheter 17.5 to 22.5 cm (7 to 9 inches). 9. The nurse is assisting the NAP to remove a Foley catheter. The nurse should intervene if which of the following actions is noted? a) The NAP explains the procedure to the patient, regardless of condition or level of awareness. b) The NAP connects an empty syringe to the balloon port and allows it to fill passively. c) The NAP makes sure the balloon is completely deflated before removing the Foley catheter. d) The NAP cleans the patient’s perineal area, hands the patient their call light, and removes gloves. Correct answer: d Rationale: To prevent the transmission of microorganisms, the NAP should remove the used gloves and perform hand hygiene before handing the patient any personal items or the call light. The patient should receive a thorough explanation of the catheter procedure, regardless of condition or level of awareness. The syringe should be allowed to fill by gravity. To prevent trauma to the patient’s urethra, the balloon should be completely deflated before removal. 10. The nurse has received an order to insert a Foley catheter in a 24 year old female patient. Which catheter would be most appropriate for this patient? a) 12 French, 5 mL balloon b) 10 French, 3 mL balloon c) 14 French, 5 mL balloon d) 16 French, 30 mL balloon e) 18 French, 5 mL balloon Correct answer: c Rationale: 14 to 16 French catheter is indicated for adult women; the smaller size catheter should be chosen first to prevent urethral trauma. 8 to 10 French with 3-mL balloon is generally used with children. 16 to 18 French with 5-mL balloon is generally used with men. 11. A patient who is 48 hours post Foley insertion is running a low-grade fever and complains of lower abdominal discomfort; his urine appears cloudy. The NAP states that his urine had a foul odor when his drainage bag was emptied. Which of the following would be an appropriate nursing action? (Select all that apply.) a) Obtain a urine specimen from the drainage bag. b) Assess the patient for back or flank pain. c) Perform a Hemoccult test on the urine. d) Obtain a physician’s order and then obtain a sterile urine specimen for culture and sensitivity. Correct answer: b, d Rationale: You should assess the patient for systemic symptoms of a UTI. It would also be appropriate to obtain a sterile urine specimen for culture and sensitivity. A urine specimen should only be obtained from the drainage bag immediately after the Foley catheter is inserted. It would be more appropriate to obtain a urine specimen for culture and sensitivity rather than for a Hemoccult test.