The nurse is assessing a patient whose 24-hour output is 2400 mL. Which finding reflects the nurse’s understanding of urine output?a. Increased outputb. Decreased outputc. Normal outputd. Balanced output
ANS: CKnow the average output range for a patient. Adult urinary output averages 2200 to 2700 mL in 24 hours.
On the basis of the nurse’s assessment of kidney function for an adult patient, which finding is normal?a. 10 mL/hrb. 20 mL/hrc. 30 mL/hrd. 100 mL/hr
ANS: CMinimum average hourly output is 30 mL.
Which activities related to urinary elimination may be delegated to a nursing assistant?a. Catheterizationb. Positioning the patientc. Evaluating alternatives to catheter used. Assessing urinary drainage
ANS: BNAP may assist with positioning the patient, focusing lighting for the procedure, and enhancing the patient’s comfort during the procedure through measures such as holding the patient’s hand or keeping the patient warm. The nurse uses sterile asepsis when inserting an indwelling or straight catheter to reduce the risk for bladder infection. The nurse evaluates possible alternatives to catheter use, and assessment is the responsibility of the nurse.
The nurse is planning care for a 12-year-old female patient who needs a Foley catheter inserted. It is most important for the nurse to use a catheter of which size?a. 5 to 6 French (Fr)b. 8 to 10 Frc. 12 Frd. 14 to 16 Fr
ANS: CGender and age determine catheter size. A 12 Fr catheter may be considered for use in young girls. The prescriber may order a larger size. For infants, 5 to 6 Fr is generally used; for children, 8 to 10 Fr with a 3-mL balloon is used; and 14 to 16 Fr is indicated for adult women.
The nurse notes that urine does not flow after a female patient is catheterized. The nurse believes that the catheter has been placed into the vagina. Which action should the nurse take?a. Remove the catheter and reinsert it.b. Irrigate the catheter with saline.c. Leave the catheter in place and insert another one.d. Insert the catheter 9 to 10 inches farther into the patient to verify that it is in the vagina.
ANS: CIf no urine appears, check whether the catheter is in the vagina. If misplaced, leave the catheter in the vagina as a landmark indicating where not to insert it, and insert another catheter into the meatus. Reinserting a catheter that has already been contaminated by vaginal exposure could lead to urinary tract infection.
Resistance is encountered during urinary catheterization of a male patient. Which action should the nurse take?a. Remove the catheter immediately.b. Apply force to insert the catheter farther.c. Ask the patient to breathe quickly through the mouth.d. Ask the patient to take slow, deep breaths.
ANS: DIf resistance to catheter insertion is encountered, have the patient take slow, deep breaths to promote relaxation while the catheter is slowly inserted. If resistance persists the patient may have an enlarged prostate or some other obstruction of the urethra.
When the balloon on an indwelling urinary catheter is inflated and the patient expresses discomfort, it is essential for the nurse to take which action?a. Remove the catheter.b. Continue to blow up the balloon because discomfort is expected.c. Aspirate the fluid from the balloon and advance the catheter.d. Pull back on the catheter slightly to determine tension.
ANS: CIf resistance to inflation is noted, or if the patient complains of pain, the balloon may not be entirely within the bladder. Stop inflation, aspirate any fluid injected into the balloon, and advance the catheter a little farther before attempting again to inflate.
The nurse is caring for a patient who has an indwelling urinary catheter. Which intervention is most important to include in this patient’s plan of care?a. Maintaining tension on the tubingb. Emptying the urinary collection bag every 24 hoursc. Cleaning in a circular motion from the meatus down the catheterd. Keeping the drainage bag on the bed or attached to the side rails
ANS: CUsing a clean washcloth, wipe in a circular motion along the length of the catheter for about 10 cm (4 inches). Allow slack in the catheter so movement does not create tension on it. Empty the drainage bag, and record amounts at least every 3 to 6 hours. The drainage bag must be below the level of the bladder; do not place the bag on the side rails of the bed.
The nurse has been ordered to perform closed intermittent irrigation of a patient’s indwelling urinary catheter. Which intervention is indicative of safe practice?a. Applies sterile glovesb. Instills 100 mL of irrigantc. Leaves the drainage tubing unclamped irrigationd. Determines the amount of urinary drainage by subtracting the amount of irrigant from the total output
ANS: DCalculate the fluid used to irrigate the bladder and catheter, and subtract from the volume drained to determine accurate urinary output. Closed intermittent irrigation does not require the use of sterile gloves. The typical amount of irrigant used is 30 to 50 mL and the tubing is clamped during the process.
When evaluating the health care team member’s ability to apply a condom catheter, it is most important for the nurse to provide further instruction for which intervention?a. Clipping of hair at the base of the penisb. Applying skin prep to the penis before catheter placementc. Using regular adhesive tape to hold the catheter in placed. Leaving 1 to 2 inches of space between the tip of the penis and the end of the catheter
ANS: CUse of an adhesive strip not designed for sheath application may be inflexible and may impede circulation to the penis. Clip hair at the base of the penis. Hair adheres to the condom and is pulled during condom removal or may get caught in rubber as the condom catheter is applied. Apply skin preparation to the penis and allow it to dry. Leave 1 to 2 inches of space between the tip of the glans penis and the end of the condom.
When providing care for a patient with a suprapubic catheter who has acquired a UTI, which intervention is most important for the nurse to implement?a. Using clean techniqueb. Securing the tube to the inner thighc. Cleansing the insertion site in a direction toward the draind. Promoting intake of 2200 mL of fluid per day
ANS: DEncourage the patient with a UTI to drink at least 2200 mL of fluid per day. The insertion site is cleansed in a circular swabbing pattern so as not to disturb the tubing. Standard care requires the use of clean gloves and securing the catheter to the abdomen.
Which symptom is the patient with fluid overload likely to exhibit?a. Oliguriab. Distended neck veinsc. Increased skin temperatured. Increased urine specific gravity
ANS: BCardiovascular signs of fluid volume excess include bounding pulse rate, normal blood pressure with or without orthostatic changes, third heart sound (S3), and distended neck veins. Oliguria is a renal sign of fluid volume deficit. Increased skin temperature is a sign of fluid volume deficit. Increased urine specific gravity is a renal sign of fluid volume deficit.
When observing a patient for symptoms of dehydration, the nurse should observe which assessment?a. Increased salivationb. Diuresisc. Periorbital edemad. Decreased capillary filling
ANS: DCardiovascular signs of fluid volume deficit include increased pulse rate, weak pulse, hypotension, decreased pulse volume/pressure, decreased capillary filling, and increased hematocrit. Increased salivation and periorbital edema are signs of fluid volume excess. Diuresis is a renal sign of fluid volume excess.
When providing care for a patient in need of an indwelling catheter, the nurse understands that which of the following is an indication for this need?a. Presence of stage III and IV pressure ulcersb. Presence a yeast infectionc. Need for inaccurate measurement of urinary outputd. Need to manage urinary elimination
ANS: AIndications for an indwelling catheter include (1) the presence of stage III and IV pressure ulcers that cannot heal because of continual incontinence, and (2) the need for accurate measurement of urinary output in critically ill patients. The incidence of catheter-associated UTI significantly decreases when the nurse gives the prescriber daily reminders to remove unnecessary catheters and suggests the use of alternative noninvasive treatments to manage urinary elimination.
The nurse receives an order to insert a Foley catheter. In obtaining a catheter of the right size, the nurse is aware that large catheters can lead to which complication?a. Urethral damageb. Bladder relaxationc. Obstruction of urinary flowd. Decreased risk for infection
ANS: ALarge catheters (larger than 16 Fr) can distend the urethra and permanently damage the urethra and bladder neck, as well as cause bladder spasms and leaking around the catheter. Use a catheter of the smallest size possible to minimize trauma and promote adequate drainage of the periurethral glands. This will decrease the risk for infection.
The nurse is caring for a patient who has an indwelling catheter attached to a drainage bag; to achieve the desired outcome of this procedure, which nursing action should be taken?a. Make sure the tubing has dependent loops to gather urine.b. Make sure the tubing is coiled and secured to the bed.c. Make sure the tubing is kinked.d. Make sure the collection bag is higher than the bladder.
ANS: BCheck the drainage tubing and the bag to make sure that the tubing does not have dependent loops and the bag is not positioned above the level of the bladder. Check to make sure that the tubing is coiled and is secured to the bed linen, is free of kinks, and is not clamped, and that the patient is not lying on it
The nurse is caring for a patient who is experiencing inadequate bladder emptying. To determine postvoid residual, which technique is most important for the nurse to implement?a. Bladder scannerb. Indwelling catheterizationc. Straight/intermittent catheterizationd. Foley catheterization
ANS: AThe bladder scan is most commonly used to measure postvoid residual (PVR); it is the least invasive method of making this determination.
The nurse is preparing the patient for a bladder scan to determine PVR. Which of the following is part of the preparation?a. Limit food intake for 2 hours before the scan.b. Begin scan 10 minutes after the patient has voided.c. Limit liquid intake for 30 minutes before the scan.d. Administer an analgesic 30 minutes before the scan.
ANS: BThe nurse will assist the patient to void, then wait 10 minutes before administering the bladder scan. There is no need to limit either food or fluids before the test. Since the test is completely noninvasive, there is no need to administer an analgesic beforehand.
In assisting a male patient in using a urinal, which of the following actions should the nurse take? (Select all that apply.)a. Assess for orthostatic hypotension.b. Assess the patient’s normal elimination habits.c. Assess for periods of incontinence.d. Prop the urinal in place if the patient is unable to hold it.e. Always stay with the patient during urinal use.
ANS: A, B, CTo assist the patient in using a urinal, the nurse should assess the patient’s normal urinary elimination habits and look for periods of incontinence. Always determine mobility status before having a patient stand to void, and assess for orthostatic hypotension if the patient has been on prolonged bed rest. If the patient is able to handle the urinal himself, allow him privacy. If the patient is unable to handle the urinal the nurse will assist by holding it.
The nurse has inserted an indwelling catheter and secured the catheter to the patient’s thigh, making sure that there is enough slack that movement will not create tension on the catheter. The nurse understands that the chief purpose of properly securing Foley catheters is to obtain which outcome? (Select all that apply.)a. Minimized risk for bleedingb. Reduced risk for bladder spasmc. Reduced risk for meatal necrosisd. Reduced risk for traumae. Increased bladder relaxation
ANS: A, B, C, DSecuring the catheter will minimize accidental dislodgment. It also will minimize risks for bleeding, trauma, meatal necrosis, and bladder spasms from pressure and traction.
Antimicrobial catheters coated with silver or antibiotics have been shown to reduce the incidence of ________________.
ANS: catheter associated urinary tract infection (CAUTI)Silver coated antimicrobial catheters have been effective in reducing incidences of CAUTI in short term catheter use
Catheter use in older adults has been associated with increased ______________.
ANS: mortalityOlder adults are at greater risk of death after the development of CAUTI. They face a greater risk of the bacteria entering the bloodstream and causing a systemic infection.
The risk for catheter-associated urinary tract infection can be reduced by using ___________ when inserting the catheter.
ANS: aseptic techniqueNumerous studies has confirmed the effect of the use of aseptic technique in the insertion of urinary catheters in reducing the rate of catheter associated infections.
A single-lumen catheter that is inserted into the bladder through the urethra only to empty the bladder and then is removed is known as a _______________ catheter.
ANS: straight or intermittentA straight or intermittent catheter is a single-lumen catheter that is inserted into the bladder through the urethra only to empty the bladder, and then is removed. Use this type of catheter on a one-time basis, for example, to determine the amount of residual urine in the bladder, or intermittently, when the patient cannot urinate because of a urinary obstruction or a neurological disorder such as spinal cord injury.
An ______________ has a separate lumen that is used to inflate a balloon so the catheter remains in the bladder for short- or long-term use.
ANS: indwelling catheterAn indwelling catheter has a separate lumen that is used to inflate a balloon so the catheter remains in the bladder for short- or long-term use.
_________________ is the volume of urine in the bladder after a normal voiding.
ANS: Residual urineResidual urine, also referred to as postvoid residual (PVR), is the volume of urine in the bladder after a normal voiding.
A noninvasive device that is used to provide accurate determination of a patient’s bladder volume by first creating an ultrasound image of the patient’s bladder and then calculating the urine volume in the bladder is known as a ______________.
ANS: bladder scannerThe bladder scanner is noninvasive, so there is no risk for nosocomial UTI and possible trauma associated with urinary catheterization. It provides accurate determination of a patient’s bladder volume by first creating an ultrasound image of the patient’s bladder and then calculating the urine volume in the bladder.
A ___________________ is a noninvasive alternative for management of male urinary incontinence. Because it is noninvasive, the risk for UTI is decreased. The device fits over the penis and connects to a small collection bag that attaches to the leg with a strap, or to a standard urinary collection bag that hangs on the bed frame below the level of the bladder.
ANS: condom catheterA condom catheter, also referred to as an external catheter or a penile sheath, is a noninvasive alternative for management of male urinary incontinence. Because it is noninvasive, the risk for UTI is decreased. The device is a soft, flexible, condom-like sheath that fits over the penis and connects to a small collection bag that attaches to the leg with a strap, or to a standard urinary collection bag that hangs on the bed frame below the level of the bladder.
__________________ involves the insertion of a urinary catheter directly into the bladder through the lower abdominal wall. Urine drains from the catheter into a urinary drainage bag.