Urinary

Question 1

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 his genitals for signs of impaired skin integrity
c. ) ask him to demonstrate proper use of a urinal
d. ) instruct him to use the call light when he is finished

Answer 1

A, 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.

Question 2

The nurse is delegating to nursing assistive personnel (NAP) the task of assisting with a urinal. The nurse specifies to NAP that the urinal is to be used in bed, not in a standing position, for which patient?

a. ) Patient admitted for hypertension and diabetes
b. ) Patient with complete left-sided paralysis caused by a stroke
c. ) Patient receiving diagnostic tests for esophageal strictures
d. ) Patient being treated for dehydration from heat exposure

Answer 2

B, The nurse would instruct the NAP not to allow the patient with complete left-sided paralysis to stand while using the urinal. Helping this patient stand is not safe for either the patient or the staff.

Question 3

Why would the nurse assess a patient’s abdomen before helping with the use of a urinal?

a. ) To determine if the patient needs a bed pan for bowel elimination
b. ) To assess for abdominal pain
c. ) To assess for bladder distention
d. ) To determine if the patient will need help using the urinal

Answer 3

C, The nurse would palpate the patient’s abdomen before assisting with a urinal in order to assess for bladder distention.

Question 4

The nurse is assisting a patient with the placement of a urinal. The patient tells the nurse, “I’ll call you when I’m done.” What is the nurse’s best response?

a. ) “All right, my name is Robin, and I’ll be right across the hall. Just call me when you’re finished.”
b. ) “Fine. Recap the urinal, hang it on your side rail, and use your call light to let me know you’re finished.”
c. ) “I’ll check on you as soon as I get a chance.”
d. ) “I’ll be back in 15 minutes. That should be enough time for you to finish up.”

Answer 4

B, This is the safest response, since it encourages the patient to handle the urinal appropriately after use and to rely on the call light to communicate his needs.

Question 5

Which action promotes infection control when assisting a patient with a urinal?

a. ) Placing a clean urinal on the overbed table
b. ) Using a waterproof pad to protect the linen from urine spillage
c. ) Applying gloves before emptying and cleaning the patient’s urinal
d. ) Asking if the patient would like to clean the genitals after using the urinal

Answer 5

C

Question 6

The nurse has delegated to nursing assistive personnel (NAP) the skill of assisting with a bedpan for a patient who has had discomfort when walking to the bathroom. Which statement made by the NAP requires the nurse’s follow-up?

a. ) “Do you still need a stool sample for the lab?”
b. ) “If I can get someone to help, I’ll walk her to the bathroom.”
c. ) “The patient reports that moving is uncomfortable for her. Has she had pain medication recently?”
d. ) “The patient told me that she’s had problems with hemorrhoids in the past.”

Answer 6

B, The NAP is not qualified to determine whether it is appropriate to ambulate the patient. The nurse has delegated the skill of assisting with a bedpan, and the NAP should carry out that responsibility as instructed.

Question 7

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 the bedside curtain.
b. ) Raise the side rail on the side opposite that on which the nurse is working.
c. ) Obtain help to place the patient on the bedpan.
d. ) Raise the bed to a comfortable working height.

Answer 7

C

Question 8

A dependent, confused patient is being given a bedpan. How can the nurse best ensure the patient’s safety?

a. ) Respond promptly to the call light.
b. ) Raise the side rails on the bed before leaving the room.
c. ) Slide one hand under the patient’s sacrum to help the patient lift off the bedpan.
d. ) Check in on the patient every 5 minutes until the bedpan can be removed.

Answer 8

B, 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.

Question 9

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 patient’s prescribed oral pain medication.
c. ) Evaluate the patient’s ability to move in bed.
d. ) Elevate the head of the bed to between 30 and 60 degrees.

Answer 9

d, 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.

Question 10

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 patient’s health care provider.
b. ) Ask if the patient has a history of hemorrhoids.
c. ) Check the medical record to see if the patient has a history of blood in the stool.
d. ) Document the observation in the medical record, indicating a need for follow-up.

Answer 10

b, 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.

Question 11

When preparing to apply a condom catheter, the nurse would do what first?

a. ) Close the door and draw the bedside curtain
b. ) Obtain the patient’s written informed consent
c. ) Clamp the drainage tubing
d. ) Offer the patient a urinal

Answer 11

a, the patient’s privacy must be protected throughout this intervention.

Question 12

Which instruction might the nurse give to nursing assistive personnel (NAP) about applying a condom catheter on a patient?

“Check for breaks in the skin before applying the catheter.”
“Determine whether the patient is still having problems with incontinence before you put the catheter on him.”
“Read the manufacturer’s instructions for applying the adhesive to secure the condom.”
“Be sure to get a snug fit between the tip of the penis and the end of the condom catheter.”

Answer 12

c, This is the best statement, since it provides NAP with direction that pertains to applying the condom catheter.

Question 13

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 condom catheter.
d. ) Use a hair guard before applying the condom catheter.

Answer 13

d

Question 14

Why would the nurse ensure that a patient’s condom catheter is not twisted?

a. ) To prevent the catheter from coming off
d. ) To make sure the catheter is the correct size
c. ) To ensure an adequate hourly urine output from the kidneys
d. ) To prevent an allergic response

Answer 14

a, 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.

Question 15

What would the nurse do for a patient who is complaining of penile pain 15 minutes after having a condom catheter applied?

a. ) Offer an antiinflammatory medication.
b. ) Drop the level of the urine drainage bag.
c. ) Remove the catheter.
d. ) Ensure that the catheter is not twisted.

Answer 15

c, 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.

Question 16

Which action would the nurse take to ensure the safety of an older adult patient who has received an enema?

a. ) Assess for the presence of external hemorrhoids.
b. ) Provide assistance to the bathroom for expulsion of fluid and stool.
c. ) Document the patient’s physical response to the enema.
d. ) Instruct the patient to attempt to retain the fluid for 2 to 5 minutes.

Answer 16

b, Assisting an older adult to the bathroom helps ensure the patient’s safety because it may prevent a fall.

Question 17

The nurse is preparing to administer an enema. How can the nurse best facilitate insertion of the rectal tube?

a. ) Place the patient in a side-lying position with the right knee flexed.
b. ) Lubricate the first 6 to 8 cm (2.5 to 3 inches) of the tip of the tube.
c. ) Flush the tube with the solution
d. ) Hold the tube in the rectum until all of the fluid has been instilled.

Answer 17

b

Question 18

The nurse is delegating to nursing assistive personnel (NAP) the administration of an enema for an older adult patient who is recovering from a stroke. The enema order reads, “Enemas until clear.” Which statement made by NAP requires the nurse to follow up?

a. ) “I’ll need help to turn her onto her side.”
b. )“It may take three or four enemas to achieve a clear return.”
c. ) “I’ll test the water temperature on the inside of my own wrist.”
d. ) “The enema will wear her out, so I’ll wait until after she ambulates.”

Answer 18

b, This statement requires follow-up, since administering more than three enemas can cause fluid and electrolyte imbalance, especially in an older adult patient. The health care provider should be notified if the bowel has not been evacuated after three enemas.

Question 19

The nurse has delegated administration of a standard enema for a 72-year-old patient with constipation. Which statement made by nursing assistive personnel (NAP) requires the nurse to follow up?

a. ) “I’ll warm up the solution before instilling it.”
b. ) “I’ll place the patient in the left side-lying position with the right knee bent.”
c. ) “I’ll put a waterproof pad under the patient before I start.”
d. ) “I’ll instill the solution and then check in on my other patients until I get the call signal.”

Answer 19

d, After instilling the solution, NAP should remain with the patient until he or she is ready to defecate.

Question 20

Which action would the nurse take to reduce the risk of infection among patients and staff when administering an enema to an older adult patient with dementia?

a. ) Lubricate the tip of the rectal tube.
b. ) Pad the patient’s bed thoroughly.
c. ) Perform hand hygiene before donning gloves.
d. ) Help the patient onto a bedpan to expel the enema fluid and stool.

Answer 20

C

Question 21

What is the primary reason the nurse ensures that a patient’s indwelling urinary catheter drainage tubing is free of kinks?

a. ) Kinks in the tubing cause the patient unnecessary discomfort.
b. ) Kinks allow the drainage bag to become overly full.
c. ) Kinks are associated with the development of urinary tract infection (UTI).
d. ) Kinks result in scant, dark amber-colored urine.

Answer 21

C

Question 22

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 temperature of 99.6° F
b. ) Pulse rate of 88 beats per minute
c. ) Redness noted on the external urethral meatus
d. ) 200 mL of pale yellow urine in the drainage bag

Answer 22

C, Redness surrounding the external urethral meatus is a sign of impaired skin integrity and should be reported to the nurse immediately.

Question 23

All of the following factors are known to increase the risk of urinary tract infection (UTI) except which one?

a. ) History of fecal incontinence
b. ) Use of an indwelling urinary catheter
c. ) Drainage tubing is kinked
d. ) Use of plain soap instead of an antiseptic cleanser for perineal hygiene

Answer 23

D

Question 24

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?

a. ) The catheter may have traumatized the labia.
b. ) The labia have contaminated the area.
c. ) The patient’s perineal area must be reassessed for infection.
d. ) The nurse must ensure that the catheter is not pulling on the bladder.

Answer 24

B

Question 25

What is the most effective way to prevent infection when providing catheter care for a patient?

a. ) Properly dispose of soiled linen.
b. ) Perform hand hygiene before positioning the patient.
c. ) Secure the catheter to the patient’s leg or abdomen.
d. ) Cleanse from the meatus outward.

Answer 25

D

Question 26

Which action would the nurse take to reduce the risk for a catheter-associated urinary tract infection (CAUTI) in a patient with an indwelling urinary catheter?

a. ) Wear clean gloves when inserting the catheter.
b. ) Inflate the balloon on the catheter before using it.
c. ) Use the smallest-size catheter possible.
d. ) Empty the urine by disconnecting the catheter from the collection bag.

Answer 26

C

Question 27

Which action(s) would minimize the patient’s risk for injury during insertion of an indwelling urinary catheter?

a. ) Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based substances
b. ) Thoroughly cleansing the patient’s perineal area with povidone-iodine solution before inserting the catheter
c. ) Performing proper hand hygiene and applying gloves before inserting the catheter
d. ) Terminating the insertion if the patient reports pain at any time during the procedure

Answer 27

A

Question 28

Which statement best illustrates the nurse’s understanding of the role of nursing assistive personnel (NAP) when inserting an indwelling urinary catheter in a female patient?

a. ) “Please direct the light to better illuminate the patient’s perineal area.”
b. ) “You need to be comfortable inserting a catheter in a patient of her size.”
c. ) “See if a size 14-French catheter is big enough.”
d. ) “Find out if the patient has any allergies to latex or iodine.”

Answer 28

A

Question 29

The nurse has completed the initial inspection of the patient’s perineum and is preparing to insert an indwelling urinary catheter. Which action would the nurse complete next?

a. ) Begin to establish a sterile field.
b. ) Open and assemble the urine drainage bag.
c. ) Remove soiled gloves, and perform hand hygiene.
d. ) Center the drape over the patient’s labia.

Answer 29

C

Question 30

A female patient placed in the dorsal recumbent position for the insertion of an indwelling urinary catheter tells the nurse that she “doesn’t feel comfortable in this position” and that her “back really hurts.” What is the nurse’s best response?

a. ) Reassure the patient that the procedure will take only a few minutes.
b. ) Promise to reposition the patient as soon as the catheter has been inserted.
c. ) Reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip.
d. ) Explain to the patient that the position will allow the catheter insertion to be more efficient.

Answer 30

C

Question 31

What is the best reason for the nurse to instruct a male patient to take slow, deep breaths during insertion of an indwelling urinary catheter?

a. ) To increase oxygenation
b. ) To reduce blood pressure
c. ) To distract him
d. ) To promote relaxation

Answer 31

D, The nurse would instruct a male patient to take slow, deep breaths during catheter insertion if the nurse felt resistance to the advancing catheter or if the patient reported pain. Deep breathing promotes relaxation, which might help to pass the catheter through the urinary sphincter.

Question 32

When preparing to insert an indwelling urinary catheter in a male patient, it is important for the nurse to do what?

a. ) Remove the cotton balls from the kit for later use.
b. ) Advance the catheter 10 to 12 inches or until urine flows.
c. ) Lubricate the first 5 to 7 inches of the catheter.
d. ) Hold the penis at a 45-degree angle during insertion.

Answer 32

C

Question 33

Which observation indicates that instruction given to nursing assistive personnel (NAP) in caring for a patient with an indwelling urinary catheter has been effective?

a. ) The collection bag has been placed on the side rail of the bed.
b. ) The excess catheter tubing has been coiled beside the patient’s inner thigh.
c. ) The collection bag has been placed on the bed.
d. ) The collection bag is held above the level of the bladder while ambulating the patient.

Answer 33

B

Question 34

Which action will the nurse implement to reduce the risk of catheter-associated urinary tract infection (CAUTI) in a male patient with an indwelling urinary catheter?

a. ) Frequently pull on the drainage system tubing.
b. ) Use the largest-size catheter possible.
c. ) Clean the urinary meatus daily.
d. ) Apply antiseptics to the urinary meatus.

Answer 34

C

Question 35

While setting up the sterile field in preparation for inserting an indwelling urinary catheter, a male patient is incontinent of urine over most of the supplies. What action would the nurse take to reduce the patient’s risk for infection?

a. ) Rinse off the supplies that were contaminated with urine.
b. ) Cleanse the patient’s urinary meatus.
c. ) Replace all contaminated supplies, and begin the process again.
d. ) Change the patient’s bed linens.

Answer 35

C

Question 36

During intermittent open bladder irrigation, a patient complains of pain. Which action would the nurse take first?

a. ) Examine the drainage tubing for clots, sediment, and kinks.
b. ) Notify the health care provider.
c. ) Leave the irrigation drip wide open.
d. ) Monitor the patient’s vital signs.

Answer 36

A

Question 37

Which action would the nurse take to minimize a patient’s risk for injury during urinary catheter irrigation?

a. ) Change the tubing every 8 hours.
b. ) Use slow, even pressure when injecting the irrigating fluid.
c. ) Adhere to aseptic technique during the irrigation process.
d. ) Monitor the patient’s temperature every 4 hours.

Answer 37

B, Using slow, even pressure during the instillation of fluid into the bladder helps avert bladder trauma.

Question 38

Which instruction might the nurse give to nursing assistive personnel (NAP) helping to care for a patient receiving bladder irrigation?

a. ) “Tell me how he tolerates the irrigation.”
b. ) “Be sure to check for signs of a urinary tract infection.”
c. ) “Measure and report the patient’s temperature to me every 4 hours.”
d. ) “Ask the patient about pain level.”

Answer 38

C

Question 39

Which action is most important in reducing the risk for infection in a patient receiving open intermittent irrigation of a urinary catheter?

a. ) Attaching the urinary drainage bag to the bed frame
b. ) Inspecting the drainage tubing for kinks
c. ) Disposing of contaminated items after the procedure
d. ) Cleaning the end of the drainage tubing with an antiseptic wipe before reconnecting it to the catheter

Answer 39

D

Question 40

Which action would the nurse take to manage continuous urinary catheter irrigation for a patient whose urine is bright red and contains clots?

a. ) Increase the irrigation drip rate.
b. ) Notify the patient’s health care provider of the blood and clots in the urine.
c. ) Encourage the patient to increase fluid intake.
d. ) Apply ice to the patient’s lower abdominal area.

Answer 40

A, The nurse would increase the irrigation drip rate to flush the urinary tract until the urine was only tinged pink with blood.

Question 41

While performing an intermittent straight urinary catheterization of a female patient, the nurse inadvertently inserts the catheter into the patient’s vagina. Which action would the nurse take next?

a. ) Remove the catheter, and rinse it thoroughly in sterile water for reuse.
b. ) Keep the catheter in place, and begin again with a new sterile catheter.
c. ) Remove the catheter, relubricate it, and insert it into the urinary meatus.
d. ) Stop advancing the catheter, and notify the health care provider.

Answer 41

B

Question 42

While attempting to perform a straight catheterization for a male patient, the nurse advances the catheter 3 to 4 inches into the meatus but observes no urine flow. Which action would the nurse take at this time?

a. ) Continue to advance the catheter until 5 to 7 inches of the catheter tube has been introduced into the urethra.
b. ) Withdraw the catheter to 1 inch, and ask the patient to cough.
c. ) Encourage the patient to cough as the catheter is advanced.
d. ) Apply pressure to the patient’s lower abdomen over the bladder.

Answer 42

A

Question 43

The nurse instructs nursing assistive personnel (NAP) regarding proper technique for intermittent straight catheterization of a male patient. Which statement made by NAP indicates that the instruction was effective?

a. ) “I’ll help you set up the sterile field.”
b. ) “I’ll get a sterile urine cup for you.”
c. ) “There are leg straps in the utility room.”
d. ) “I’ll help keep his legs away from the sterile field.”

Answer 43

D

Question 44

Why does the nurse cleanse a female patient’s perineum before inserting an intermittent urinary catheter?

a. ) To encourage the bladder to drain fully
b. ) To encourage spontaneous voiding
c. ) To prevent bowel elimination during the procedure
d. ) To reduce the patient’s risk of urinary tract infection

Answer 44

D

Question 45

The nurse has completed an intermittent straight urinary catheterization of a female patient. Which action would the nurse delegate to nursing assistive personnel (NAP)?

a. ) Measure and empty the urine.
b. ) Palpate the abdomen.
c. ) Ask the patient if she has any pain.
d. ) Document the procedure.

Answer 45

A

Question 46

Why does the nurse need to keep the urine sterile while obtaining a sample from an indwelling urinary catheter?

a. ) Sterile technique protects the patient from microorganisms in the urine.
b. ) Sterile technique protects the nurse from microorganisms in the urine.
c. ) Sterile technique reduces the amount of pain caused by the procedure.
d. ) Sterile technique ensures that microorganisms in the specimen are from the urine, and not the result of contamination.

Answer 46

D

Question 47

Which action will ensure that a sterile urine specimen is handled properly in order to help obtain reliable results?

a. ) Placing the specimen in a biohazard bag
b. ) Having someone take the specimen to the lab immediately
c. ) Cleaning the outside surface of the container
d. ) Ensuring that a stock of sterile urine collection kits is available

Answer 47

B, within 20 minutes

Question 48

Which statement might the nurse make to nursing assistive personnel (NAP) before delegating the collection of a routine urine sample from a patient with an indwelling urinary catheter?

a. ) “Does the patient understand why the specimen is needed and why we cannot obtain it from the Foley bag?”
b. ) “See if the catheter is causing the patient any problems and if he is having any pain.”
c. ) “Please get two sterile urine collection containers from the utility room.”
d. ) “Let me know if the urine contains blood or sediment, or appears cloudy.”

Answer 48

D

Question 49

Which measure may be taken to minimize the staff’s risk for infection from a urine specimen?

a. ) Firmly securing the lid of the urine specimen container
b. ) Using a sterile urine specimen container
c. ) Using a sterile syringe to access the sampling port
d. ) Placing the urine specimen container in the refrigerator until the laboratory comes to get it

Answer 49

A

Question 50

When collecting a urine specimen from an indwelling urinary catheter, which action is most likely to ensure that sufficient urine is collected?

a. ) Checking the patency of the indwelling catheter tubing
b. ) Placing the urinary collection bag below the level of the bladder
c. ) Clamping the catheter tubing for 15 minutes before collection
d. ) Asking the patient to drink a glass of water 30 minutes before the collection

Answer 50

C

Question 51

When preparing to discharge a patient who had an indwelling urinary catheter removed 24 hours ago, the nurse would offer patient education regarding which common complication?

a. ) Urinary incontinence
b. ) Urinary tract infection
c. ) Adequate oral hydration
d. ) Kidney stones

Answer 51

B, A urinary tract infection may develop 2 to 3 days after indwelling urinary catheter removal, and the nurse would educate the patient to be alert for signs and symptoms of such an infection.

Question 52

Which action would best minimize a patient’s risk for infection during removal of an indwelling urinary catheter?

a. ) The nurse or nursing assistive personnel (NAP) removing the catheter must employ clean technique.
b. ) A registered nurse, not NAP, must remove the catheter.
c. ) Catheter removal must be executed within 10 minutes of beginning the procedure.
d. ) Catheter removal must take place within 5 days of catheter insertion.

Answer 52

A

Question 53

Which statement might the nurse make to nursing assistive personnel (NAP) caring for a patient who has just had an indwelling urinary catheter removed?

a. ) “Teach the patient the signs of a urinary tract infection.”
b. ) “Tell me when and how much the patient first voids.”
c. ) “Explain that voiding might be uncomfortable for 4 to 5 days.”
d. ) “Assess the patient for a distended bladder before the end of the shift.”

Answer 53

B

Question 54

Which nursing action minimizes a patient’s risk for injury during removal of an indwelling urinary catheter?

a. ) Using a 5-mL syringe to deflate the balloon
b. ) Using sterile scissors to cut the valve to deflate the balloon
c. ) Tugging gently on the catheter to pull the balloon through the urethra
d. ) Checking the documentation for the volume of fluid used to inflate the balloon

Answer 54

D, Checking the volume of fluid used to inflate the balloon in order to ensure the balloon is completely deflated before removal is the nursing action that will minimize a patient’s risk for injury during removal of an indwelling urinary catheter.

Question 55

Which is not an expected outcome on a first voiding after catheter removal?

a. ) Mild burning
b. ) Fever and back pain
c. ) Producing only a small amount of urine
d. ) Discomfort

Answer 55

B, The nurse would instruct the patient to report signs of a urinary tract infection, such as fever and back pain. These signs are unlikely to be present during the patient’s first voiding after catheter removal.

Question 56

A patient with a suprapubic catheter is complaining of pain. What will the nurse do first to help this patient?

a. ) Ensure that the patient is not lying on the drainage tubing
b. ) Instruct the patient to increase his or her oral fluid intake
c. ) Observe the rate of drainage in the urine collection bag
d. ) Notify the health care provider

Answer 56

A

Question 57

What is the primary reason the nurse applies sterile gloves rather than clean ones when caring for a patient with a newly inserted suprapubic catheter?

a. ) To protect the nurse and other patients from pathogens
b. )To collect a sterile urine sample
c. ) To reduce the patient’s risk of infection
d. ) To reduce the patient’s risk of injury

Answer 57

C

Question 58

Which nursing action reduces the risk of injury in a patient with a suprapubic catheter?

a. ) Applying sterile gloves before cleaning the catheter insertion site
b. ) Cleansing the skin surrounding the insertion site
c. ) Securing the catheter to the abdomen
d. ) Keeping the drainage bag above the level of the patient’s bladder

Answer 58

C, Securing the catheter to the abdomen will reduce the risk of injury to the patient by ensuring that excess tension is not applied to the catheter. Such tension could damage the bladder.

Question 59

A newly inserted suprapubic catheter becomes dislodged. What action should the nurse perform first?

a. ) Notify the health care provider
b. ) Apply pressure over the site
c. ) Cover the site with a sterile dressing
d. ) Help the patient into a side-lying position

Answer 59

C

Question 60

After bacteria are cultured from a midstream urine specimen, what is accomplished by sensitivity testing?

a. ) Confirms the accuracy of the results of the culture
b. ) Identifies the immune system’s reaction to the presence of the bacteria
c. ) Determines whether the patient is allergic to the antibiotic agent with which the provider plans to treat the infection
d. ) Determines which antibiotic agent is most effective in killing the bacteria

Answer 60

D, Sensitivity testing of a bacterial culture determines which antibiotic the bacteria are most vulnerable (sensitive) to and therefore which agent is likely to be the most effective in killing them.

Question 61

What can the nurse do to help ensure an accurate result when collecting a midstream urine sample for a patient who is menstruating?

a. ) Notify the health care provider.
b. ) Make a note on the lab slip that the patient is menstruating.
c. ) Postpone the specimen collection until menses has ceased.
d. ) Do nothing other than follow normal procedure, since menstruation will not affect the results.

Answer 61

B

Question 62

Which statement might the nurse make to nursing assistive personnel (NAP) assigned to collect a midstream urine specimen from a patient with signs of a urinary tract infection?

a. ) “Obtain 30 to 60 mL of midstream urine.”
b. ) “The urine has a foul odor.”
c. ) “Teach the patient to collect the urine specimen.”
d. ) “Be sure to maintain aseptic technique.”

Answer 62

D

Question 63

Which statement might the nurse make to nursing assistive personnel (NAP) in order to help ensure reliable results of culture and sensitivity testing of a midstream urine specimen?

a. ) “I’ll need a biohazard bag to put the specimen into.”
b. )“Please get the specimen to the lab within 20 minutes.”
c. ) “After you replace the cap, please wipe any drops of urine from the outside of the container.”
d. ) “We are out of specimen collection kits.”

Answer 63

B

Question 64

What is the most important action the nurse can take to ensure that a midstream urine specimen does not become contaminated?

a. ) Wear sterile gloves to open the sterile specimen kit.
b. ) Ensure that the patient’s perineum has been cleansed before the specimen is obtained.
c. ) Determine if the patient has any known allergies.
d. ) Have the patient rate his or her current pain level.

Answer 64

B

Question 65

Testing with a urine reagent test strip shows that a patient’s urine is positive for protein, negative for glucose and blood, and has a pH of 8.2. What will the nurse do in response to these results?

a. ) Check the medical record for further instructions from the health care provider.
b. ) Notify the health care provider of the results of the test.
c. ) Retain the sample, and retest it to confirm the results.
d. ) Obtain a double-voided urine specimen.

Answer 65

B

Question 66

Which action is necessary for an accurate chemical reaction when testing urine with a reagent test strip?

a. ) Hold the test strip in the urine for 10 seconds before completing the test.
b. ) Compare the test strip vertically against the container.
c. ) Wear clean treatment gloves while handling the strip.
d. ) Keep the test strip horizontal while timing the process.

Answer 66

D

Question 67

Which statement will the nurse make to nursing assistive personnel (NAP) when delegating urine glucose testing with a reagent strip for a patient with type 2 diabetes?

a. ) “Be sure to wear sterile gloves when testing the urine.”
b. ) “Make sure urine sits for a full minute post void to read for ketones.”
c. ) “Check our supply of urine glucose test strips.”
d. ) “Don’t forget to get a double-voided specimen when you test the patient’s urine.”

Answer 67

D

Question 68

What is a double-voided urine specimen?

a. ) Any urine sample that is not contaminated with either feces or toilet tissue
b. ) A second urine specimen taken about 30 minutes after the patient voids
c. ) The first of two samples obtained from the patient’s first voiding of the day
d. ) A urine sample divided into two clean containers to be tested separately

Answer 68

B

Question 69

Which action is performed initially when using a reagent strip to test the urine of a patient with type 1 diabetes for glucose?

a. ) Apply clean treatment gloves.
b. ) Verify the patient using two patient identifiers.
c. ) Discard the urine after the patient voids.
d. ) Encourage the patient to drink a glass of fluid.

Answer 69

B