Chapter 15 Flashcards
After a Foley catheter has been removed, the nurse should assess the patient for:
a. hemorrhage.
b. constipation.
c. urinary retention.
d. bladder spasm.
c. urinary retention.
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
a. Cleansing the first 2 in of the catheter with soap and water every shift
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.
d. Advance the catheter into the bladder.
When explaining the difference between a colostomy and an ileostomy, the nurse explains
which of the following about an ileostomy?
a. It is always permanent.
b. It drains semiliquid stool.
c. It has a much larger stoma.
d. It does not need a pouch.
b. It drains semiliquid stool.
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
a. Tip of the nose to the earlobe 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? (Select all that apply.)
a. At least every hour
b. At patients request
c. Before each meal
d. At bedtime
e. Upon waking up in morning
C , D, E
The nurse administers an enema to a patient as ordered. What should be documented?
(Select all that apply.)
a. Date
b. Time
c. Type and volume of enema
d. Temperature of solution
e. Characteristics of results
f. How patient tolerates procedure
A, B, C, D, E, F
