a nurse is likely to receive an order for urinary catheterization of a newly admitted pt who
answer
is in the ICU for a gastrointestinal bleed
R: precise measurement of urinary output is crucial for managing fluid balance in pt's who are critically ill
question
a nurse is planning on obtaining a urinary specimen from a pt's closed urinary system. Identify the sequence of steps the nurse should take.
answer
1) Wipe port with alcohol swap
2) Insert a 10 mL syringe and needle into port.
3)Withdraw 5 mL of urine
4) Transfer the urine to a sterile specimen container
5) Transport the specimen to the lab
question
a nurse is assessing a pt's indwelling urinary catheter drainage at the end of the shift and notes the output is considerably less than the fluid intake. What actions should the nurse take first?
answer
Check the catheter for kinks
R: output that is considerably less than intake is a sign that the catheter is blocked. The first action the nurse should take is to check the tubing for kinks and ensure the clients urine flow is not obstructed
question
A nurse is applying a condom catheter for an older adult pt who is uncircumcised. What is an appropriate step in the procedure?
answer
leaving a space between the penis and catheter's tip
R: a space of 2.5 to 5cm should be left between the tip of the penis and the end of the catheter. this space helps prevent irritation of the tip of the penis and allows full drainage of urine,
question
when providing perineal care for a female pt who has an indwelling urinary catheter, what areas should the nurse cleanse last?
answer
anus
R: the basic aseptic principle applicable to perineal care is to cleanse from the area of least contamination to the area that is most contaminated. the anal area is typically contaminated with coliform bacteria and should be cleansed last.
question
a nurse is preparing to insert an indwelling urinary catheter for a female pt. When beginning the insertion procedure, the nurse should instruct the pt to
answer
bear down
R: bearing down as if to void relaxes the external sphincter and aids in the insertion procedure.
question
What actions should a nurse take when removing a pt's indwelling urinary catheter?
answer
deflate the balloon completely before removal
R: if any inflation solution remains in the balloon, trauma to the urethral canal is likely w/ removal of the catheter
question
a nurse who is preparing to insert a straight urinary catheter for a male pt should
answer
apply light traction to the penis
R: lifting the penis to a position perpendicular to the body while applying light traction straightens the urethral canal to facilitate insertion
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