Nokea
You are about to catheterize a female patient who is experiencing a decline in her physical condition. In fact, she is being transferred from your unit to the ICU. As you get ready to insert the catheter, the tip lightly brushes against the patient's leg. Which of the following possible actions should you perform next?
- A. You should get a new catheter to insert.
- B. You should report the possible contamination to the nurse in the ICU so that she can get an order for antibiotics.
- C. It is not necessary to mention it as long as you cleaned the urinary meatus according to policy.
- D. You should clean the catheter tip with alcohol or Betadine.
Correct Answer: A
Rationale: A catheter that touches the skin is contaminated and must be replaced to prevent infection.
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Stress incontinence
- A. Incontinence related to inability to get to the bathroom
- B. The brain does not receive a message that the bladder is full
- C. Incontinence related to bladder spasms and contractions
- D. The bladder does not empty because of an obstruction
- E. Incontinence related to weak pelvic floor muscles
- F. Loss of urine with no warning
Correct Answer: E
Rationale: Stress incontinence occurs due to weak pelvic floor muscles, causing urine leakage during activities like coughing or sneezing.
If a patient had an order to discontinue a catheter the day after surgery, under what circumstances might you consider delaying doing so until you talk with the physician?
- A. If the patient complained of burning or discomfort because of the catheter
- B. If the patient's output is greater than 50 mL/hr
- C. If the patient's output is less than 30 mL/hr
- D. If the patient's urine is dark amber
Correct Answer: C,D
Rationale: Low urine output (<30 mL/hr) or dark amber urine may indicate inadequate kidney function or dehydration, warranting consultation before catheter removal.
A tube that remains in the bladder is an , also known as a double lumen catheter or a Foley catheter.
- A. Straight catheter
- B. Indwelling catheter
- C. Condom catheter
- D. Suprapubic catheter
Correct Answer: B
Rationale: An indwelling catheter, such as a Foley catheter, is designed to remain in the bladder for continuous urine drainage.
You are caring for a patient with an indwelling catheter. You have an order to discontinue the catheter this morning. The patient also has had an IV infusing at 100 mL/hr through the night. The patient is taking liquids and eating ice chips. At 7:00 a.m., you notice that the output on the previous shift was 290 mL of dark amber urine and the patient's intake totaled 960 mL. Which action will you take?
- A. Get an order to irrigate the catheter prior to discontinuing it.
- B. Wait to discontinue the catheter until you can speak with the physician on morning rounds.
- C. Discontinue the catheter and discontinue the order for intake and output because the patient no longer has a tube in place.
- D. Perform a bladder scan to determine if the patient has a large amount of residual urine in the bladder.
Correct Answer: B
Rationale: Low output (290 mL) compared to high intake (960 mL) and dark amber urine suggest possible retention or dehydration, warranting physician consultation.
Contraction of which muscle causes the bladder to empty?
- A. Internal urinary sphincter
- B. Detrusor
- C. External urinary sphincter
- D. Peristalsis
Correct Answer: B
Rationale: The detrusor muscle contracts to expel urine from the bladder during voiding.