Lab 2 and 3

Question 1

Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order.
a Insert and advance catheter.
b Lubricate catheter.
c Inflate catheter balloon.
d Clean urethral meatus with antiseptic.
e Drape patient with the sterile square and fenestrated drapes.
f When urine appears, advance another 2.5 to 5 cm (1 to
2 inches).
g Prepare sterile field and supplies.
h Gently pull catheter until resistance is felt.
i Attach drainage tubing.

1 g, d, e, b, a, f, c, h, i
2 e, g, b, d, a, f, c, h, i
3 g, e, b, d, f, a, c, h, i
4 d, e, g, b, a, f, h, c, i

Answer 1

2

Question 2

The nurse is preparing to remove an indwelling urinary catheter. Which nursing interventions should the nurse implement? (Select all that apply.)
1 Attach a 5-mL syringe to the inflation port.
2 Allow the balloon to drain into the syringe by gravity.
3 Initiate a voiding record/bladder diary.
4 Pull catheter quickly.
5 With steady force, pull back on the syringe plunger

Answer 2

2, 3.
By allowing the balloon to drain by gravity, the
development of creases or ridges in the balloon may be avoided, minimizing trauma to the urethra during withdrawal. All patients who have a catheter removed should have their voiding monitored with a voiding record or bladder diary. The size syringe used to deflate the balloon is dictated by the size of the balloon. Catheters
should be pulled out slowly and smoothly. Pulling fluid out of the balloon with force can cause the formation of creases or ridges in the balloon.

Question 3

The urine flow has stopped in a patient’s indwelling urinary catheter, and the nurse assesses tenderness and distention over the lower abdomen. What would be an initial nursing action?
1 Irrigating the catheter with sterile water or saline
2 Assessing the catheter drainage tubing for kinking
3 Encouraging fluid intake
4 Removing the catheter

Answer 3

2. The most appropriate action would be to ensure that
   the catheter is not occluded. Fluids should not be encouraged if the catheter is blocked. Irrigation and catheter removal are more invasive interventions that may be appropriate, depending on the cause of the decreased urine flow.

Question 4

Which patient condition is appropriate for the insertion of an indwelling urinary catheter?
1 Stage I pressure ulcer exposed to leaking urine
2 Patient unable to independently toilet
3 Elevated postvoid residual
4 Urinary incontinence

Answer 4

3. Evidence-based guidelines support the use of indwelling catheters in the presence of urinary retention. Another indication for catheterization is healing of open sacral or perineal wounds in incontinent patients. A stage I ulcer is not an open wound but would require close observation. All other patient conditions are not appropriate for an indwelling catheter because of the increased risk for catheter-associated urinary tract infection (CAUTI)

Question 5

Which size indwelling urinary catheter is best for an adult female patient?
1 18 Fr, 5-mL balloon
2 16 Fr, 30-mL balloon
3 14 Fr, 5-mL balloon
4 12 Fr, 30-mL balloon

Answer 5

3 Rationale: Evidenced-based guidelines for the prevention of CAUTI support the use of the smallest size catheter and balloon possible, which in an adult is a size 14 Fr, 5 mL balloon

Question 6

A patient with hematuria has a three-way indwelling urinary catheter with continuous bladder irrigation (CBI) and is complaining of lower abdominal pain. What should be the nurse’s first action?
1 Increasing the rate of the CBI
2 Checking urine flow to the drainage bag
3 Decreasing the rate of the CBI
4 Taking the patient’s temperature

Answer 6

2 Rationale: An appropriate first action would be to assess the patency of the drainage system. Urine output in the drainage bag should be more than the volume of the irrigant solution infused.
If the system is not draining urine and irrigant, the irrigant should be stopped immediately. The catheter may be occluded, and the bladder distended.

Question 7

A patient tells the nurse that the health care provider said his sutures are coming out today. Which nursing action is most important before removing the sutures?
1 Assembling the required equipment
2 Checking that there is a health care provider’s order for the suture removal
3 Performing hand hygiene in view of the patient
4 Explaining to the patient what will be happening during the suture removal

Answer 7

2. Rationale: If there is no order for the suture removal, none of the other steps need to be taken. Nurses cannot remove staples or sutures merely because of something the health care provider said.

Question 8

A patient has an extensive abdominal wound and is to have half of the staples removed and the incision line cleaned. Which actions should the nurse take during the preparation and actual interaction with the patient? (Select all that apply.)
1 Position the patient in a semi-Fowler’s position.
2 Place upper tip of staple remover under staple to ease
removal.
3 Administer an analgesic 30 minutes before staple removal.
4 Lift up on the staple when depressing the extractor handles.
5 Clean the incision before removing the staples, starting at the sides next to the incision.

Answer 8

3. Rationale: The patient should be premedicated because of the wound size. He or she should be positioned as flat as possible. You place the lower tip of the staple remover under the staple, and you do not lift up on the staple when depressing the extractor handles.
   The incision cleaning is started at the top of the incision and not the sides. When half the staples are removed, it means that every other staple is removed. This allows observation of how the wound is healing. In some instances small strips of tape, called Steri-Strips,
   will be used where the staples were removed to help stabilize the tissue.

Question 9

The patient is to have sutures removed from his back after surgery. The nurse is performing the procedure correctly by taking which step?
1 Snipping the suture at the end proximal to the knot
2 Wiping the area with a disinfectant swab to prevent wound infection
3 Removing the suture in a smooth, continuous manner
4 Holding the scissors in the nondominant hand and the
pickups in the dominant hand

Answer 9

3. Rationale: The suture should be removed in a smooth, continuous manner.
   1 wrong: The knot should have been snipped at the end distal to the knot.
   4 wrong: The scissors should have been held in your dominant hand, and the pickups in your nondominant hand.
   2 wrong: Disinfectants are never used on living tissue because of their harsh chemical action. Antiseptics may be used on skin to remove organisms.

Question 10

A patient with hematuria has a three-way indwelling urinary catheter
with continuous bladder irrigation (CBI) and is complaining of lower
abdominal pain. What should be the nurse’s first action?
1 Increasing the rate of the CBI
2 Checking urine flow to the drainage bag
3 Decreasing the rate of the CBI
4 Taking the patient’s temperature

Answer 10

2
Rationale: An appropriate first action would be to assess the
patency of the drainage system. Urine output in the drainage bag
should be more than the volume of the irrigant solution infused.
If the system is not draining urine and irrigant, the irrigant should
be stopped immediately. The catheter may be occluded, and the
bladder distended.

Question 11

A nurse is performing a neurologic assessment. Which approach is
most effective in obtaining accurate data when testing sensory
pathways?
1 Perform each test quickly.
2 Have the patient as relaxed as possible.
3 Compare symmetric areas.
4 Use a predictable order of assessment.

Answer 11

3
Rationale: Comparison of areas side to side is extremely important in evaluating a patient’s neurologic system. This prevents omissions between the affected and unaffected areas.

Question 12

In teaching a patient about skin lesions, the nurse knows that teaching has been successful when the patient identifies which lesion as
abnormal?
1 A symmetric lesion
2 A lesion with regular edges and borders
3 One that is blue/black or varied in color
4 One that is less than 7 mm in diamete

Answer 12

3
Rationale: A lesion colored blue/black or with variegated, nonuniform pigmentation or variations/multiple colors (tan, black) with
areas of pink, white, gray, blue or red may indicate melanoma.

Question 13

6Ps of neurovascular assessment

Answer 13

Pain,
poikilothermia (unable to maintain core temp) [temperature],
paresthesia (tingling) [sensation],
paralysis [movement]
pulselessness,
pallor [colour]

Question 14

When performing the wound assessment, the nurse notes that the
wound base is covered with red, moist granulation tissue. What does
the presence of granulation tissue signify in wound healing? Provide
a rationale for your answer

Answer 14

Granulation tissue is composed of new blood vessels that will bring
nutrients and oxygen to the tissue. This type of tissue must be present
for the wound to heal. Once a wound is filled with granulation tissue,
healing will progress; thus a wound filled with granulation tissue is a
good finding

Question 15

Components of wound charting (11)

Answer 15

1. site
2. size (LWD)
3. appearance: necrotic/sloughy/ granulating/epithelising/ sutures intact…
4. exudate amount: nil/low/moderate/high
5. exudate type: serum/blood/pus
6. surrounding skin: healthy/dry or scaly/macerated/inflammed/rashes/edematous…
7. offensive odour: yes/no
8. wound pain: yes/no
9. treatment aim: deslough/absorption/protect/comfort
10. cleansing solution
11. wound products: list inner to outer layer

Question 16

name 2 examples of surgical drains

Answer 16

hemovac and jackson-pratt (JP)

Question 17

uhmm maybe not as impt as the rest

The nurse notes approximately 60 mL of bright red drainage in the
Jackson-Pratt drain 6 hours after surgery. Which nursing interventions should be included in the care for this patient? (Select all that
apply.)
1 Emptying the drain 24 hours from now
2 Pinning the drainage tubing to the patient’s gown
3 Placing Vaseline gauze around the tube insertion site
4 Securing the drain above the level of the wound
5 Emptying the drain now
6 Squeezing the drain flat before putting in the drainage plug

Answer 17

2, 5, 6
Rationale: The drainage needs to be emptied, measured, and
recorded. After you have emptied the drainage, you need to
depress or squeeze the drain flat before putting in the plug. This
helps the suction mechanism to work. Attaching the drain to the
patient’s gown below the level of the wound helps to prevent the
drain from pulling and also keeps it in a dependent position to
allow for maximum drainage

Question 18

In preparing to irrigate a wound, which intervention helps to reduce
the risk for infection during wound irrigation? (Select all that apply.)
1 Using sterile technique
2 Directing the flow of solution from healthy tissue to infected
tissue
3 Warming irrigation solution to body temperature
4 Cleaning suture line after doing wound irrigation
5 Irrigating with a continuous pressure of 3 psi

Answer 18

1, 2

Question 19

The nurse needs to empty the Jackson-Pratt drain collection device
every 8 hours. After draining the fluid from the container, how
should he or she reestablish the closed suction system?
1 Close the port after emptying the drain
2 Compress the bulb portion of the container and close the port
3 Pump the container several times before closing
4 Leave 10 mL of wound fluid in the container to keep the level
of suction constant

Answer 19

2
Rationale: A Jackson-Pratt drain is a closed suction setup. Once
the collector is drained, push out the air by compressing the drain
and closing it. When the collector is drained, all the exudate is
removed, and the collector is not pumped.

Question 20

6Ps

wound documentation:
When applying a dressing or bandage, you should report the following to the healthcare provider:
* if the client develops a ___
* if you notice an increase in ___ from the wound
* if you notice a worsening in the appearance of the wound or the skin around the wound

For a wound secured by a bandage, let the healthcare provider know:
* if you notice any __ change in the skin
* if the client reports __ or __

Document:
* the __ of dressing you applied
* how you secured the dressing
* the appearance of the __ and ___
* any unusual observations about the wound
* the __ and __of your observations

Answer 20

wound documentation:
When applying a dressing or bandage, you should report the following to the healthcare provider:
* if the client develops a fever
* if you notice an increase in drainage from the wound
* if you notice a worsening in the appearance of the wound or the skin around the wound

For a wound secured by a bandage, let the healthcare provider know:
* if you notice any color change in the skin
* if the client reports numbness or tingling

Document:
* the type of dressing you applied
* how you secured the dressing
* the appearance of the wound and exudate
* any unusual observations about the wound
* the date and time of your observations