Nokea
You have just inserted an indwelling catheter in a 56-year-old male patient with urinary retention due to an enlarged prostate. You notice that the drainage bag is filling quickly, with 750 mL of urine almost immediately draining into it. Which of these actions will you take?
- A. Clamp the catheter after 1,000 mL has drained to prevent bladder collapse.
- B. Clamp the catheter after 1,200 mL has drained to prevent hematuria.
- C. Take no action because the patient is tolerating rapid bladder decompression without problems.
- D. Remove the catheter after 1,500 mL has drained and call the health-care provider.
Correct Answer: C
Rationale: Rapid drainage is normal in urinary retention, and no action is needed if the patient is tolerating it without symptoms like pain or hematuria.
You may also like to solve these questions
What is the minimum acceptable hourly urine output?
- A. 15 mL
- B. 30 mL
- C. 60 mL
- D. 90 mL
Correct Answer: B
Rationale: The minimum acceptable hourly urine output is 30 mL to indicate adequate kidney function.
Total 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: F
Rationale: Total incontinence involves continuous urine leakage without warning or control.
also known as overactive bladder, is the inability to keep urine in the bladder long enough to get to the restroom.
- A. Urge incontinence
- B. Stress incontinence
- C. Overflow incontinence
- D. Functional incontinence
Correct Answer: A
Rationale: Urge incontinence is characterized by a sudden, intense urge to urinate followed by involuntary loss of urine, often due to an overactive bladder.
The urethra is a tube that, in males, is surrounded by prostate tissue. When the prostate enlarges, it encroaches on the urethra and narrows it. When catheterizing a male patient with an enlarged prostate, you may encounter resistance. How should you respond to this situation?
- A. Remove the catheter immediately and call the health-care provider.
- B. Continue to try to advance the catheter. If bleeding occurs, leave the catheter in place and call the health-care provider.
- C. Gently twist the catheter to try to pass the tip past the area of prostate enlargement.
- D. Remove the catheter and try a larger size.
Correct Answer: C
Rationale: Gently twisting the catheter can help navigate past the obstruction caused by an enlarged prostate.
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.