Quiz 15 Elimination And Gastric Intubation Flashcards
A nurse has an order for a removal of an indwelling catheter. What are the correct nursing interventions to prevent injury when removing the catheter?
Deflate the catheter balloon
After Foley catheter has been removed, the Nurse assess says the client carefully for?
Urinary tract infection
If the solution container for the enema is held above the correct height
Fast running solution causes dis tension and cramping
He charge nurse in a long-term care facility is observing another nurse whose inserting indwelling catheter into a female client. Which of the following actions by the nurse should prompt the charge nurse to intervene?
The nurse separates the clients labia with her dominant hand
The nurse has an order for an indwelling catheter insertion on a new client. What is the primary reason for the nurse to use sterile technique?
To avoid introduction of micro organisms
The north was preparing to position a mail client for a urinary catheterization. In what position should the nurse place the client?
Supine with thighs slightly abducted
The nurse at a healthcare facility is caring for elderly and immobile client with urinary incontinence. The client has been pleased with the Foley catheter. For what purpose is a Foley catheter used in a client?
To maintain skin integrity
A nurse is administering a cleansing and I’m a first client who has constipation. Which of the following actions should the nurse take?
What’s a container solution 30 cm or 12 inches above the anus
After inserting a nasogastric tube the nurse would check for proper placement by which methods?
Gurgling or swishing sound heard with a stethoscope over the stomach when air is injected into the tube, the ability to aspirate gastric contents with the syringe
What is considered a non-invasive method of collecting urine from the incontinence patient
Condom catheterization
I nurse is removing the fecal impaction of a client what positioning is recommended for the patient?
Sims
Well catheterizing a female client, The nurse answers the catheter into an opening 4to 5 inches and no urine is detected. The most likely reason for this is that?
The catheter is in the vagina
What is the correct procedure to test the integrity of the balloon of an indwelling catheter?
Inject and aspirate normal saline or sterile water
A nurse is caring for a client who complains of the loss of small amount of urine when she sneezes or laughs. What nursing intervention should the nurse suggest for the client?
Keagle exercises
Well receiving a 500 ML soapsuds enema, the client states, I am beginning to feel like I have to go to the bathroom after administering 200 ML’s of solution. Which of the following things would best help the client overcome the urge to defecate?
Clamp the tubing for a short time
A nursing student is administering a water and soap solution animal to a client. Which of the following steps should the nurse perform to purge air from the tubing?
Open the clamp and fill the tube with solution
The nurse outlines routine catheter care to the nursing assistant as….
Cleaning with soap and water the first 2 inches of the catheter every shift
A nurse whose left hand is dominant and is preparing to perform a Catheterization for a client who is a paraplegic. Which of the following actions should the nurse take
Stand on the clients right side
A nurse is planning to insert an end to all the catheter for an adult female client. Which of the following actions should the nurse plan to take?
Lubricate the catheter 3 1/2 to 5 cm
The nurse is assessing that urine output in a client with an indwelling Foley catheter. Which location is recommended to best assess urine characteristics?
Assess urine in the drainage tubing
A nurse is caring for a client who reports constipation. The physician has prescribed an enema, what is the correct order when performing an enema?
Confirm the client identity they checking her arm band, provide for the clients privacy by closing the curtains, assist the client in to Sims position, insert the tip of the enema tubing into the clients rectum
The nurse instruct the patient to be diligent in cleaning fecal matter from around the stoma because it can cause which complication?
Irritation of the stoma, skin breakdown around the stoma
A nurse is preparing to perform a catheterization to Tina specimen for a client. The client informs the nurse that she is concerned about her privacy during the procedure. Which of the following actions should the nurse take?
Close the door and cover the client during the procedure
A nurse is administering a tap water enema to a client. The client reports cramping and as the nurse insert solution. Which of the following actions should the nurse take to relieve the clients discomfort?
Lower the height of the solution container
When inserting the urinary catheter into a mail client and I’m feeding the balloon, the patient grimaces and looks uncomfortable. What is the appropriate nursing action?
Withdraw fluid from the balloon and advanced catheter Forward
When considering the female perineum before catheterization, the nurse will?
Cleanse with strokes from front to back
Which of the following clients is at higher risk for fecal impaction?
Bedrest and pour fiber intake
A nurse student has been assigned to insert an indwelling catheter in to a mail client. When should the students inflate the balloon during the insertion of the catheter?
After seeing urine in tubing then advance one to 1 1/2 inch more
The nurse suspects that the urinary catheter has been accidentally placed in the clients vagina what are the nurses next action?
Leave the catheter in place and is there another sterile catheter into the meatus
A nurse is providing instructions to the nurse assistant on the catheter care for this patient. And appropriate instructions asked to
Clean from the urinating meatus down the catheter
Bladder training instructions are being given to a patient who has a history of urinary incontinence. The nurse should give the patient which instruction?
Void every one and a half to two hours while you are awake
What is the size range for urethral catheter’s?
14 to 24 French
What would the nurse do to determine the correct distance to insert a nasogastric tube?
Measure from the tip of the nose to the ear lobe to the syphoid process
