Assisting with elimination Flashcards
What is the primary reason the nurse ensures that a patient’s indwelling urinary catheter drainage tubing is free of kinks?
Kinks are associated with UTI’s. and can obstruct the flow of urine into the drainage bag.
The nurse has delegated measurement of a patient’s vital signs and catheter care to nursing assistive personnel (NAP). Which observation should the NAP report to the nurse immediately?
a. Rectal temp of 99.9
b. Pulse of 88 BPM
c. Redness on external urethral meatus
d. 200ML of pale yellow urine in bag
C. Redness surrounding the external urethral meatus should be reported immediately. It is a sign of impaired skin integrity and should be reported to the nurse immediately.
All of the following factors are known to increase the risk of urinary tract infection (UTI) except which one?
a. Hx of fecal incontinence
b. Use of indwelling catheter
c. Drainage tubing kinked
d. Use of plain soap instead of antiseptic for perineal area
D. Use of an antiseptic cleanser has not been shown to decrease the risk of catheter-associated urinary tract infection (CAUTI). Mild soap and warm water are adequate for perineal hygiene during catheter care
While performing catheter care, the nurse moves her hand, allowing the patient’s labia to close around the catheter. Why would the nurse repeat this part of the care?
The nurse will repeat the perineal care because the labia closed around the catheter and contaminated the perineal area.
What is the most effective way to prevent infection when providing catheter care for a patient?
a. Proper disposal of soiled linen
b. Hand hygiene before positioning patient
c. Secure cath to patients leg or abdomen
d. Cleanse from meatus outward
c. Cleanse from meatus outward. Securely holding the catheter and cleansing from the meatus outward is the most effective way to prevent infection when providing catheter care.
When preparing to apply a condom catheter, the nurse would do what first?
a. Close door and draw bedside curtain
b. Obtain patients written informed consent
c. Clamp the drainage tubing
d. Offer the patient a urinal
A. close the door and draw curtain for privacy before beginning
Which instruction might the nurse give to nursing assistive personnel (NAP) about applying a condom catheter on a patient?
a. Check for breaks in the skin before applying the cath
b. determine whether the patient is still having problems with incontinence before you put the cath on him
c. read the manufacturers instructions for applying the adhesive to secure the condom
d. be sure to get a snug fit between the tip of the penis and the end of the condom cath
C. Read manufacturers instructions for applying adhesive. This is the only instruction that pertains to applying the catheter.
Which instruction would the nurse give to nursing assistive personnel (NAP) to ensure the patient’s comfort when a condom catheter is applied?
a. wash the penis before applying the catheter
b. clip the drainage bag to the bed
c. wear gloves when applying the cath
d. use a hair guard before applying the condom cath
d. Use hair guard
Why would the nurse ensure that a patient’s condom catheter is not twisted?
To prevent the cath from coming off. A twisted condom obstructs urine flow, causing urine pooling, skin irritation, and weakening and deterioration of the adhesive. These factors can cause the catheter to come off.
What would the nurse do for a patient who is complaining of penile pain 15 minutes after having a condom catheter applied?
If a patient complains of pain 15 minutes after a condom catheter is applied, the nurse should remove the catheter and assess the patient to determine the cause of the pain.
A patient with a nasogastric tube, an intravenous infusion line, and an indwelling urinary catheter needs to be placed on the bedpan. Which action would the nurse take first to ensure the patient’s safety?
a. close bedside curtain
b. raise side rail on the side opposite that on which the nurse is working
c. obtain help to place the patient on a bedpan
d. raise bed to comfortable working height
c. Obtain help to place patient on bedpan. For a patient with a drain, tube, or intravenous line, the nurse’s first action to ensure the patient’s safety would be to obtain help to place her on the bedpan.
A dependent, confused patient is being given a bedpan. How can the nurse best ensure the patient’s safety?
a. Respond promptly to call light
b. Raise side rails on bed before leaving the room
c. Slide one hand under the patient sacrum to help them lift off the bedpan
d. Check in on the patient every 5 min. until bedpan can be removed.
b. Raise the side rails on the bed before leaving the room. Raising the side rails on the bed is the best safety intervention to minimize the risk of falling if the patient attempts to get out of bed without assistance.
The nurse is assisting with a bedpan for a patient who had knee surgery 24 hours ago. What is the best way for the nurse to maximize comfort while the patient uses the bedpan?
a. Raise the knee gatch
b. offer a dose of the patients Px oral pain med
c. Evaluate the patients ability to move in bed
d. Elevate the head of the bed between 30 and 60 degrees.
d. Elevate the head of the bed. Elevating the bed to a more natural position is the best way for the nurse to improve the patient’s comfort. Doing so prevents hyperextension of the neck, supports the upper torso as the patient raises the hips, and promotes defecation.
After assisting with a bedpan, the nurse notes that the patient’s stool is streaked with bright-red blood. What would the nurse do first?
a. Notify the health care provider
b. Ask patient if they have a Hx of hemorrhoids
c. Check med records to see if there is a Hx of blood in stool
d. Document the observation in the medical record, indicating need for follow-up
b. Ask if there is Hx of hemorrhoids. Asking whether the patient has a history of hemorrhoids is the most appropriate initial response, followed by documentation of the observation and notification of the patient’s health care provider.
A male patient on bed rest is permitted to stand to use the urinal. Which action would the nurse take to ensure his safety before helping him to a standing position?
a. Determine his risk for orthostatic hypotension
b. Assess genitals for signs of impaired skin integrity
c. Ask him to demonstrate proper use of the urinal
d. Instruct him to use the call light when he is finished
A. Determine risk for orthostatic HTN.
Since the patient is on bed rest, he is at risk for orthostatic hypotension. Assessing for this condition would help ensure that the patient could stand safely to use the urinal.
