Nokea
You are caring for a patient who sustained a spinal cord injury 14 years ago. Two days ago, the health-care provider inserted an indwelling urinary catheter, size 18 Fr, which is to remain in place for several weeks to allow pressure ulcers to heal. The patient has had catheters off and on for many years. You note that urine is leaking around the catheter insertion site and that the patient's meatus is getting red and irritated. Which of the following actions represents the nursing interventions most likely to resolve this situation?
- A. Request medication to calm bladder spasms, which are probably the cause of the leakage.
- B. Obtain an order to remove the current catheter and replace it with a size 22 Fr catheter.
- C. Obtain an order to replace the current catheter with a size 14 Fr catheter.
- D. Obtain an order to remove the current catheter and replace it with a condom catheter.
Correct Answer: C
Rationale: A smaller catheter (14 Fr) may reduce irritation and leakage, as a larger catheter can cause pressure and inflammation at the meatus.
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Which emotional response do you think most people will experience when they need to ask for assistance with urinating?
- A. Fear related to a possible 'accident'
- B. Anger related to diminished sense of self-control
- C. Shame/embarrassment related to loss of autonomy
- D. Loss of self-esteem related to inability to care for self independently
Correct Answer: C
Rationale: Needing assistance with urination often causes shame or embarrassment due to the loss of privacy and autonomy.
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.
Which independent nursing measure would you implement?
- A. Encourage fluid intake
- B. Perform a bladder scan
- C. Administer a diuretic
- D. Insert a new catheter
Correct Answer: B
Rationale: Performing a bladder scan is an independent nursing action to assess for urinary retention in a patient with low voiding volumes.
You are teaching an aide to perform catheter care. Which of the following represents an accurate statement?
- A. Clean the perineum and a few inches of tubing using a perineal wash and a washcloth or gauze in downward strokes away from the body.
- B. Wash the perineum with a soapy washcloth using circular motions.
- C. Wash from the tubing 3 to 4 inches from the insertion site up toward the meatus.
- D. Separate the labia if the patient is female and wash first on one side, then the other, and then down the middle.
Correct Answer: A,D
Rationale: Cleaning downward from the meatus and separating the labia to clean thoroughly prevents infection by moving away from the insertion site.
The nursing assistant tells you that Mrs. White gained 3 pounds since her daily weigh the previous morning. You are most concerned that Mrs. White
- A. Has been eating too many calories in the past 24 hours.
- B. Is retaining approximately 1.5 liters of fluid since yesterday.
- C. Is not getting enough movement and exercise while in the hospital.
- D. Was dehydrated yesterday and has replaced needed fluids.
Correct Answer: B
Rationale: A 3-pound weight gain in 24 hours likely indicates fluid retention (1 kg ? 1 liter), equivalent to about 1.5 liters, which requires further assessment.