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A nurse receives a prescription to catheterize a patient following surgery. What nursing action reflects correct technique?
- A. Planning to use different equipment for catheterization of male versus female patients
- B. Selecting the smallest appropriate size indwelling urinary catheter
- C. Sterilizing the equipment prior to insertion
- D. Avoiding filling the balloon with sterile water to prevent pressure on tissues
Correct Answer: B
Rationale: The smallest appropriate indwelling urinary catheter should be selected to aid in prevention of CAUTIs in the adult hospitalized patient. The equipment used for catheterization is usually prepackaged in a sterile, disposable tray and is the same for both male and female patients. Most kits already contain a standard-sized catheter. Catheters are graded on the French (F) scale according to lumen size, with 12 to 16 Fr gauge commonly used. A 14F, 5-mL or 10-mL balloon is usually appropriate, unless ordered otherwise.
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A nurse in the emergency room is teaching a patient how to collect a midstream urine specimen. What instructions will the nurse give the patient?
- A. Wash your hands with soap and water.
- B. Open the container and place the lid face down on the counter.
- C. Separate your labia and wipe with the antiseptic towelettes in the kit.
- D. Without letting go of the labia, void a small amount into the toilet or collection hat.
- E. Lean the collection container against the urinary opening and void into the container.
- F. Void an ounce, then remove the container and finish voiding in the toilet.
Correct Answer: A,C,D
Rationale: The nurse gives these instructions to collect the midstream/clean-catch urine specimen: Wash your hands with soap and water. Open the collection cup, and place the lid face up; do not touch the inside. Separate the labia and cleanse the urinary opening with soap and water or towelettes included in the kit. Void about 1 oz. (30 mL) into the toilet, then move the collection cup close to the urinary opening and void about 1 oz (no less than 2 teaspoons) into the container. Pass the remainder of the urine into the toilet. Without touching the inside of the lid, close the cup and return it to the nurse.
A nurse is caring for a patient who is taking phenazopyridine (a urinary tract analgesic) for a UTI. The patient states, 'My urine was bright orange-red today; I think I'm bleeding. Something is terribly wrong.' How will the nurse best respond?
- A. The medication causes a red-orange tinge to the urine; it is expected.
- B. I will test your urine for blood.
- C. This may be the result of an injury to your bladder.
- D. I'll hold the medication and let the provider know you are allergic to the drug.
Correct Answer: A
Rationale: Phenazopyridine, a urinary tract analgesic, can cause orange or orange-red urine; the nurse educates the patient to expect this change.
A nurse is caring for a patient with an enlarged prostate who has had an indwelling catheter for several weeks. A prescription for continuous bladder irrigation (CBI) is written after the patient developed hematuria post cystoscopy. The nurse teaches the patient the purpose of CBI is to prevent what situation?
- A. Catheter infection due to long-term use
- B. Need to flush the catheter of organisms post procedure
- C. Blood clots that could block the catheter
- D. Need for increased fluid intake
Correct Answer: C
Rationale: Post procedure continuous bladder irrigation, in the presence of hematuria, prevents stasis of blood and clot formation potentially obstructing urine output. In the absence of hematuria, clots or debris, natural irrigation of the catheter through increased fluid intake by the patient is preferred. It is preferable to avoid catheter irrigation unless necessary to relieve or prevent obstruction.
A nurse in the gynecology clinic is preparing an educational brochure to teach patients how to prevent UTIs. Which teaching points would the nurse include?
- A. Wear underwear with a cotton crotch.
- B. Take baths rather than showers.
- C. Drink of six to eight 8-oz glasses of liquid per day.
- D. Urinate before and after intercourse.
- E. After defecation, dry the perineal area from the front to the back.
- F. Observe the urine for color, amount, odor, and frequency.
Correct Answer: A,C,D,E
Rationale: It is recommended that a healthy adult drink six to eight 8-oz glasses of fluid daily, dry the perineal area after urination or defecation from the front to the back, and observe the urine for color, amount, odor, and frequency. It is also recommended to wear underwear with a cotton crotch, take showers rather than baths, and drink two glasses of water before and after sexual intercourse and void immediately after intercourse. Observing urine characteristics will not prevent a UTI; however, this observation may help a patient notice an infection.
A nurse is caring for a male patient who had a urinary sheath applied following hip surgery. What nursing interventions are appropriate to include when caring for this patient?
- A. Preventing the tubing from kinking to maintain free urinary drainage
- B. Changing the sheath weekly and provide hygiene
- C. Fastening the sheath tightly to prevent the possibility of leakage
- D. Having the patient maintain bedrest to prevent the sheath from slipping off
- E. Leaving 1 to 2 inches (2.5 to 5 cm) beyond the tip of the penis
- F. Ensuring the device does not restrict blood flow.
Correct Answer: A,E,F
Rationale: Maintaining free urinary drainage is a nursing priority. Institute measures to prevent the tubing from becoming kinked and urine from backing up in the tubing. The catheter should be allowed to drain freely through tubing that is not kinked. Nursing care of a patient with a urinary sheath includes skin care to prevent excoriation. Remove the condom daily and wash the penis with soap and water, and dry it carefully. Care must be taken to fasten the sheath securely enough to prevent leakage, yet not so tightly as to constrict the blood vessels in the area. The tip of the tubing should extend 1 to 2 inches (2.5 to 5 cm) beyond the tip of the penis to prevent irritation to the sensitive glans area. Confining a patient to bedrest increases the risk for hazards of immobility.