Nokea
During insertion of a Foley catheter the patient grimaces as the balloon is inflated. What is the immediate reaction of the nurse?
- A. Withdraw the catheter.
- B. Ask the patient to bear down.
- C. Continue to inflate the balloon.
- D. Advance the catheter into the bladder.
Correct Answer: D
Rationale: Grimacing is a sign of pain indicating that the balloon might be in the urethra instead of the bladder. The catheter should be advanced before inflation.
You may also like to solve these questions
After a Foley catheter has been removed the nurse should assess the patient for:
- A. hemorrhage.
- B. constipation.
- C. urinary retention.
- D. bladder spasm.
Correct Answer: C
Rationale: While an indwelling urinary catheter is in place, the bladder loses tone and can retain urine after the removal of the catheter.
Before inserting a nasogastric tube what measurement should the nurse take?
- A. Tip of the nose to the earlobe to the xiphoid process
- B. Bridge of the nose to the xiphoid process
- C. Nose to the top of the ear to the stomach
- D. Clavicular notch to the stomach
Correct Answer: A
Rationale: The measurement is from the tip of the nose to the ear lobe to the xiphoid process.
Bladder training is initiated on a patient preparing for discharge to home from an acute care setting. When should voiding times be scheduled?
- A. At least every hour
- B. At patients request
- C. Before each meal
- D. At bedtime
- E. Upon waking up in morning
Correct Answer: C,D,E
Rationale: Typical voiding times are upon rising, before each meal, and at bedtime. When initiating bladder training the nurse should assist the patient to void as scheduled, check the patient for wetness periodically, and remind or assist the patient to the toilet as scheduled.
A ____ tube is a flexible hollow tube that is passed into the stomach via the nasopharynx.
Correct Answer: nasogastric
Rationale: A nasogastric tube is a flexible, hollow tube that is passed into the stomach via the nasopharynx.
What would be the correct explanation of catheter care?
- A. Cleansing the first 2 in of the catheter with soap and water every shift
- B. Disinfecting the entire catheter with alcohol every shift
- C. Lubricating the catheter with antiseptic lotion every 24 hours
- D. Cleansing the meatal-catheter junction every 24 hours
Correct Answer: A
Rationale: The first 2 in of the catheter should be cleaned with soap and water every shift or more often if the patient is incontinent. Alcohol and lotions are contraindicated. Catheter care should be done every shift.