NURSE

A. B. C. D.

JEANNE IS INSERTING A URINARY CATHETER INTO A CLIENT WHO IS EXTREMELY ANXIOUS ABOUT

THE PROCEDURE.

THE

NURSE CAN FACILITATE THE INSERTION BY ASKING THE CLIENT TO:

INITIATE A STREAM OF URINE. BREATHE DEEPLY. TURN TO THE SIDE. HOLD THE LABIA OR SHAFT OF PENIS.

Answer B. When inserting a urinary catheter, facilitate insertion by asking the client to breathe deeply. Doing this will relax the urinary sphincter. Initiating a stream of urine isnt recommended during catheter insertion. Turning to the side or holding the labia or penis wont ease insertion, and doing so may contaminate the sterile field.

A female client with an indwelling urinary catheter is suspected of having a urinary tract infection. Nurse Angel should collect a urine specimen for culture and sensitivity by: a. disconnecting the tubing from the urinary catheter and letting the urine flow into a sterile container. b. wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle. c. draining urine from the drainage bag into a sterile container. d. clamping the tubing for 60 minutes and inserting a sterile needle into the tubing above the clamp to aspirate urine.

Which of the following is a primary nursing intervention necessary for all patients with a Foley Catheter in place? a. Maintain the drainage tubing and collection bag level with the patients bladder b. Irrigate the patient with 1% Neosporin solution three times a daily c. Clamp the catheter for 1 hour every 4 hours to maintain the bladders elasticity d. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity

2. When a female client with an indwelling urinary (Foley) catheter insists on walking to the hospital lobby to visit with family members, nurse Rose teaches how to do this without compromising the catheter. Which client action indicates an accurate understanding of this information? a. The client sets the drainage bag on the floor while sitting down. b. The client keeps the drainage bag below the bladder at all times. c. The client clamps the catheter drainage tubing while visiting with the family. d. The client loops the drainage tubing below its point of entry into the drainage bag.

Answer B. To maintain effective drainage, the client should keep the drainage bag below the bladder; this allows the urine to flow by gravity from the bladder to the drainage bag. The client shouldnt lay the drainage bag on the floor because it could become grossly contaminated. The client shouldnt clamp the catheter

drainage tubing because this impedes the flow of urine. To promote drainage, the client may loop the drainage tubing above not below its point of entry into the drainage bag.