- A nurse is caring for a client who has an indwelling urinary catheter. Which of the following information should the nurse include? Correct Answer(s): D A. Question: 135. The client reports sudden pain and urethral spasm. The patient does not have dysuria, urgency, frequency, or odor. Which of the following actions should the nurse take?, A nurse is caring for a group of newly admitted clients. Gavin Isaac Indwelling Urinary Catheter Insertion and Care. If this happens, try sitting in 8 to 10 A nurse is assessing a client with an indwelling urinary catheter for signs of a catheter-associated urinary tract infection (CAUTI). A client who has an indwelling urinary catheter should have a continuous urine flow w/o an accumulation of urine in the bladder; therefore, the nurse should irrigate the catheter to resolve any existing blockage. An ultrasound reveals an extremely distended bladder, and the physician orders immediate placement of A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. 4. Which of The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. Many agencies require two nurses for the insertion of indwelling catheters. ) Contact B. 2 Check for kinks in the tubing. An indwelling catheter is a flexible plastic tube that's inserted into the urethra, providing continuous drainage from the bladder into a collection bag. The nurse is caring for a client with incontinence who has an order for a catheterized urine specimen to evaluate the presence of a urinary tract infection. of long-term care residents, and 11% of home care patients have indwelling urinary catheters (Felix, Bellush, & Bor, 2014; Hooton et al. A male patient who requires an indwelling catheter should be in supine or Fowler's position. Which of the following actions should the nurse Study with Quizlet and memorize flashcards containing terms like The nurse provides discharge planning for a group of clients for which client does the nurse request a health care providers referral for home health care services, The nurse observe to unlicensed assistive personnel do you mean a client electronic medical record they are both assign A straight catheter is a urine drainage tube inserted but not left in place. The urine in the indwelling urinary catheter bag, is dark red. bradypnea, A nurse is caring for a client who has a left renal calculus and an indwelling urinary catheter. The client has an acute urinary retention 2. Three days later, the client develops a urinary tract infection. Which action should the nurse take first? 1. Begin by assessing the Indwelling Urinary Catheter (IDC): A catheter which is inserted into the bladder, via the urethra and remains in situ to drain urine. Empty the drainage bag once a day. The collection bag has been placed on the side rail of the bed. Which factors should be included in the client A nurse is caring for a client who has just undergone surgery to create an ileal conduit for urinary elimination via a stoma. The nurse should identify that the client has which of the following types of infections?, A nurse is preparing to administer an enema when the Study with Quizlet and memorize flashcards containing terms like the nurse is caring for a client with an indwelling urinary catheter. What should the nurse discuss with the health care provider before catheterization type and size of the catheter to be used Explanation: Before catheterization, the nurse should inquire about the type and size of the catheter to be used and if the a nurse is caring for a client who has been prescribed an indwelling urinary catheter. Which of the following actions should the nurse take? Choose matching definition The first criterion to be met is that the client has had an indwelling urinary catheter in place for more than 2 calendar days (day 1 being device placement while in the hospital); the device was in place on the day of onset of a UTI; and the presence of at least one of the following: temperature greater than 100. When preparing to insert the catheter, the nurse should first open the sterile package in which of the following directions? Away from the body. diaphoresis c. Secure the tubing with adhesive tape to the lower abdomen. a. a nurse is caring for a female client who has an indwelling catheter with a urinary drainage system. The nurse assesses for allergies, explains the procedure to the client, and asks unlicensed assistive personnel to perform perineal care while equipment is gathered. Arrange the following steps in the correct order. light yellow, clear D. Emptying the urinary collection bag every 24 hours c. Replace the When following evidence-based practice, which of the following actions should the nurse take first?A) Plan to initiate a bladder retraining program for the client. A client who had an indwelling urinary catheter removed 5 hr and has not voided. This tube carries urine from the bladder to the outside of the body. 2 Fixation and stabilisation of the urethral catheter 55 Insert an indwelling urinary catheter B. Family history D. D) The nurse should remove the water from the balloon by withdrawing it with a syringe. This method helps clients maintain autonomy and encourages self-care. Using soap and water, wipe away from the urinary meatus. The client has an indwelling urinary catheter in place. , 2010; The Joint Commission, 2011). Below Match the sequence of steps the nurse should take to complete this order. A nurse is providing perineal care for a female client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation? Perform perineal care before inserting a urinary catheter and regularly thereafter. " 2. Cleaning in a circular motion from the meatus down the catheter d. Daily use of soap and water should be used around the urinary meatus. Which of the following information should the nurse include in the teaching?, A nurse is giving a change-of-shift report about a client he admitted earlier that day who has Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client receiving bolus feedings via a nasogastric (NG) tube. Indwelling urinary catheter output of 25mL/hr C. Before providing care, the nurse observes the licensed practical nurse (LPN) standing outside the client's room and donning personal protective equipment as The nurse receives an order to obtain a urinary specimen from a patient's indwelling urinary catheter. , 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 nurse recognizes this finding can be a manifestation of which of the following urinary alterations? A nurse is assessing a client who has an indwelling urinary catheter and determines that the catheter is in place and functioning properly. supine Lynn P. Centers for Medicare & Medicaid Services (CMS). ) Pale yellow, clear urine C. Study with Quizlet and memorize flashcards containing terms like a charge nurse is discussing the responsibility of nurses caring for clients who have clostridium difficile. Wrapping the adhesive tape securely around the base of the penis 3. which of the following responses should the nurse make Which of the following instructions should the nurse include in the teaching?, A nurse is caring for a 58 year old client with an indwelling catheter that was placed on admission 3 days ago. Deflate the balloon completely before removal C. bradycardia b. 4 min read. 3 - Explain to the client that she will feel temporary discomfort 4 - Arrange the sterile items on the sterile field. Which action would the nurse implement to prevent the client from developing a urinary tract infection? 1. Study with Quizlet and memorize flashcards containing terms like A nurse is assessing a client who is 4 hr postoperative following a transurethral resection of the prostate and has an indwelling urinary catheter in place. What action should the nurse take next? 1. , The nurse has just inserted an indwelling urinary catheter for a maleclient. Instruct the client to A nurse is caring for a male client who has been prescribed an indwelling urinary catheter. Caring for a catheter can be embarrassing for both of you. When the nurse explains the procedure, the client refuses to allow placement of the catheter. Provide a referral for nutrition counseling B. , The nurse is caring for a client with an indwelling urinary catheter secondary to neurogenic bladder. An indwelling urinary catheter helps drain urine from your body when you can’t do it on your own. Term. Nurses' NotesVital SignsDiagnostic ResultsNurses' NotesDay 1:#14 indwelling urinary catheter to gravity, draining clear yellow urine. The client complains of Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client with an indwelling urinary catheter secondary to neurogenic bladder. A person may have trouble urinating. For 95% of patients, indwelling Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a postoperative client with an indwelling urinary catheter. 1b Meatal cleansing when catheter is in place 52 6. -A client who has urge incontinence. , A nurse is caring for a female client with an indwelling urinary catheter. What should be the nurse's response?, The client has an indwelling catheter and a urinalysis is ordered. Urination can be voluntarily controlled after the stoma heals from the initial surgery. What is the priority action? 1 Irrigate the indwelling catheter. " 3. Compared to the usual straight catheter, this one has an inflated balloon inside that acts to hold the tube in place without any obstructions or leakages. Labia minora. C. Perineum. Vesicoureteral reflux d Using indwelling urinary catheters c. Subtract the amount of irrigant used The nurse is working in the emergency department (ED). Administer pain medication to the client C. Arrange the sterile items on the sterile field The nurse is caring for a client with an indwelling urinary catheter secondary to neurogenic bladder. For which of the following clients should the nurse suspect to Which of the following statements should the nurse make?, A nurse is caring for a client within the intimate zone of the client's personal space. ) Dark yellow, cloudy urine B. The nurse completes a prescription to obtain a urine specimen from the catheter. Which rationale for indwelling urinary catheter insertion is most appropriate? 1. Dorsal recumbent position Rationale: For placing an indwelling catheter in a female patient, the nurse should have the patient in dorsal recumbent position. Place in order the steps the nurse should take when inserting the urinary catheter. . Exhibit 2 - VS Day Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has pharyngeal diphtheria. 4 Assess the patient's intake. How should the nurse obtain this Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client with severe diarrhea. Philadelphia: Wolters Kluwer; 2015. Inserts the catheter 2. Ensure there are no kinks in the drainage tubing. Which nursing action has the highest priority? a. The nursing student inserts an indwelling urinary catheter for a female patient prior to surgery. 1a Meatal cleansing before insertion 52 6. client reports of nausea c. The nurse has just completed documentation and is entering another client's room. A nurse is caring for a group of newly admitted clients. Which of the following types of transmission precautions should the nurse initiate? A. USE OF THE GUIDELINE A client is to have an indwelling urinary catheter inserted. Set up a sterile field with catherization supplies 4. Client in the step-down unit c. They are often preferred over an indwelling urethral catheter for long-term urinary drainage. B) Teach the Check the catheter tubing for kinks or twisting. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Obtain assistance as needed to facilitate patient positioning, visualization, and insertion. A client admitted with urinary retention has an indwelling urinary catheter prescribed. " D. 6. [1] . Regularly offer the client a urinal. Perform hand hygiene before and after insertion, as well as during any When caring for clients with urinary catheters and other indwelling catheters, it is necessary to ensure hand hygiene before and after catheter insertion, using a sterile technique when inserting the catheter, and When preparing to insert an indwelling urinary catheter, it is important to use the nursing process to plan and provide care to the patient. How could the nurse describe the Study with Quizlet and memorize flashcards containing terms like A nurse is applying a condom catheter for a client who is uncircumcised. Wipe with hydrogen peroxide to eliminate bacteria. Which of the following actions should the a client comes into the emergency department (ED) by ambulance with a hip fracture after slipping and falling while at home. The nurse suspects that the client is developing a urinary tract infection. Study with Quizlet and memorize flashcards containing terms like Match the medications with the corresponding urinary tract side effect. He is being discharged with an indwelling urinary catheter. A client arrives stating the inability to empty the bladder for the past three days. Offer 200 ml of fluid every 2 hours while awake d. Comatose client with A. Urine output 600mL8hrDay 2 :#14 indwelling urinary catheter to gravity, draining cloudy yellow urine. What nursing Study with Quizlet and memorize flashcards containing terms like A nurse is completing the admission assessment of a client who has a kidney stone. Collect a weekly urine specimen. -The client reports nausea and vomiting. Maintaining tension on the tubing b. serum WBC count 15,000/mm3 A nurse is caring for a client who has a history of dysrhythmias. 4° F (38° C), suprapubic Study with Quizlet and memorize flashcards containing terms like A client experiences difficulty in voiding after an indwelling urinary catheter is removed. "I will instill normal saline bullets to liquefy secretions. An increase in oral fluid intake b. Which of the following actions should the A nurse is caring for a client who has an indwelling urinary catheter. Irrigate the indwelling urinary catheter with a syringe D. Which of the following actions should the nurse instruct the client to perform during the insertion procedure?, A nurse is applying a condom catheter for a client who is uncircumcised. nurses, advanced practitioners, registered dieticians, and other A nurse is caring for a client who is postoperative following a laparotomy and has an indwelling urinary catheter and a Jackson-Pratt drain in place. c. The health care provider has prescribed an indwelling catheter for a client. Insert an indwelling urinary catheter. What is the first action by the nurse?, The nurse is caring for a female client with an indwelling urinary catheter. Select all that apply A. Peri-care and Urinary Catheter care is provided in tandem. 5 cm]) d) Once urine drains, advance the catheter another 2 to 3 inches (2. Place the client in a dorsal recumbent position 3. Explain to the client that she will feel temporary discomfort D. A review of the client's data collection reveals the client has a A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. "I will allow at least 20 seconds between suctioning passes. What should the nurse consider as the possible cause?, What action should be A nurse is assessing a client who has an indwelling urinary catheter and determines that the catheter is in place and functioning properly. c) Remove obvious encrustations from the external catheter surface by washing it gently with soap and water. ) Urine with a slight red tint Types of catheters. Which of the following assessment findings is inconsistent with this disease process? Study with Quizlet and memorize flashcards containing terms like A nurse inserts an indwelling urinary catheter for a client who is preoperative. Which of the following findings should the nurse expect? A. Blood-tinged urine in the drainage bag B. About Your Urinary (Foley) Catheter: How To Clean and Care for It 8/9 The nurse is planning care for a client with an indwelling urinary catheter. Document output from the urinary collection bag 2. Diagnostic Results. Take the client's temperature every 4 hours The nurse is caring for a client who is hospitalized and has an indwelling urethral catheter. -In adults, the amount of urine voided typically does not depend on fluid intake and losses. The inappropriate use of urinary catheters in acute care hospitals ranges fro m 21% to 63%, and often there is no documentation of Study with Quizlet and memorize flashcards containing terms like 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?, Which action(s) would minimize the patient's risk for injury during insertion of an indwelling urinary catheter?, Which statement best Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a group of newly admitted clients. An indwelling catheter may be required, Urinary catheterization is a medical procedure that involves the insertion of a thin, flexible tube into the bladder through the urethra or a surgical opening in the abdomen. Push the catheter upward toward the bladder. Which action should the nurse take into consideration to reduce the client's risk of developing a urinary tract infection (UTI)? The nurse is caring for a client with concerns of urinary incontinence. Wipe with alcohol swabs to eliminate bacteria. You can fly on an airplane with a catheter. Study with Quizlet and memorize flashcards containing terms like , A nurse is caring for a client who has acquired an infection from a visitor. clear, colorless, The nurse is caring for a client who A nurse is caring for a female client who is prescribed an indwelling urinary catheter. Diuretic use, A nurse is caring for a client who has an indwelling urinary Study with Quizlet and memorize flashcards containing terms like The nurse is attempting to insert a urinary catheter into a female client's bladder and realizes the catheter has been inserted into the vagina. What is the correct action by the nurse? 7. During the catheter insertion the tip of the urinary catheter inadvertently touches the nurse’s scrub top. , The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. A nursing assistant is caring for an older male client with cystitis who has an indwelling urinary catheter. ) Droplet C. restrict the client's fluid intake b. Place the drainage bag flat on the floor when the A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. For which complication does the nurse carefully monitor? a. The indwelling urinary catheter was removed in the post-anesthesia care unit per the surgeon's orders. Lubricate the first 5 to 7 inches of the catheter. Where should the nurse obtain a clean void urine sample Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a group of newly admitted clients. Department of Health & Human Services (DHHS). In some cases, you may need to use a Foley catheter permanently. Urinary output 100 mL in indwelling urinary catheter over last 6 hr. Flank discomfort, A nurse is caring for a client with an The nurse is caring for a client who has had an indwelling urinary catheter for 2 weeks. , Which of a student nurse's statements A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. How should the nurse obtain this specimen? a. Rationale: Suprapubic catheters are associated with decreased risk of contamination with organisms from fecal material, elimination of damage to the urethra, a higher rate of client satisfaction, and a lower risk of catheter-associated urinary tract A condom catheter is to be used for an adult male client in the extended care facility. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. "Limit fluids to no more than 1 L (34 oz) during waking hours. after the catheter has been anchored properly, what is an 1. absent urine output for 1 hr d. Slide 7: The DO's of Indwelling Urinary Catheter Care 2,3,6,7. Which approach to hygiene should the nurse take with this client?, An older adult client recently suffered a stroke. It is used for weeks straight as it is regarded as safe and A home care client has an indwelling catheter connected to a leg bag. Before cane-assisted ambulation instructions A client enters the post-anesthesia care unit with a three way indwelling urinary catheter that has a continuous irrigation of normal saline infusing. Hold adipose tissue out of the way during catheter insertion 3. b) Keep the drainage bag on the bed with the client. The student explains to the client the urinary catheter will be clamped for 10 Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client who reports burning upon urination, and an ongoing sense of needing to urinate. Care for an Indwelling Urinary Catheter. Add more sterile water to the catheter balloon. The nurse is caring for a patient who has an indwelling urinary catheter. The nurse determines that this difficulty most likely is related to: 1 Fluid imbalance 2 Sedentary lifestyle 3 Interruption in previous voiding habits 4 Nervous tension following the procedure, Which Study with Quizlet and memorize flashcards containing terms like A sterile urine specimen for culture and sensitivity has been ordered for a client who has an indwelling urinary catheter. Which of the After your indwelling urinary catheter is removed, there are things you can do to take care of yourself. Which urine characteristics does the nurse anticipate?, A client with urinary incontinence is prescribed incontinence briefs. A nurse is caring for a client who has a left renal calculus and an indwelling urinary catheter. Assist the client with daily cleansing b. Place the client Study with Quizlet and memorize flashcards containing terms like A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions should the nurse take first? A. strongly aromatic, dark amber C. Prolonged use of General Tips. Tell the client that incontinence happens with aging c. The client has several areas of skin breakdown in the perineum. Identify the correct sequence The nurse is caring for a client with a suprapubic urinary catheter. Tell the client to expect to feel a tugging sensation on removal, A nurse is providing perineal care for a female client who has an indwelling urinary catheter. The nurse has reinforced discharge instructions regarding home care to a client following a prostatectomy for cancer of the prostate. nocturia d. Perform a routine cleansing of the perineal area 2. Which of the following actions should the nurse take? a. 5. Study with Quizlet and memorize flashcards containing terms like The nurse is inserting an indwelling urinary catheter for a male client. Perform perineal care before inserting a urinary catheter and regularly thereafter. "Try to block the urge to urinate until the next scheduled time. 5-5 cm). Which of the following areas should the nurse cleanse last? Urethral meatus. Which of the following actions should the nurse take first? 1. Lipase C. Which of the following actions should the nurse take? Coil the tubing on the bed above the collection bag Collect a sterile specimen from the urinary drainage bag Secure the tubing with adhesive tape to the lower abdomen Instruct The nurse has entered the client's room to adjust settings on the intravenous pump. At 10 am, the nurse assesses the hourly urinary output as 20 mL. Begin by assessing the appropriateness of inserting an indwelling catheter according to CDC criteria as discussed in the “Preventing CAUTI” section of this chapter. ", 3. ) Airborne D. Hypocalcemia B. 1. Place the following steps in the correct order. The client is Study with Quizlet and memorize flashcards containing terms like , The USASN has been asked to collect a sterile urine specimen from an indwelling urinary catheter. Inserts the The nurse is caring for a client who needs an indwelling urinary catheter inserted for urinary retention. "Suctioning will be limited to a maximum of three catheter passes. For this client, the nurse plays a key role in prevention of which most common complication? a) chronic urinary retention b) uncontrolled suprapubic pain c) unsuppressed bladder spasms d) catheter-associated A nurse is caring for a client who has been prescribed an indwelling urinary catheter. Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to insert an indwelling urinary catheter for a male client which of the following locations should the nurse secure the urinary catheter tubing ?, A nurse is responding to a parent's question about his infants expected physical development during the first year of life c) Advance the catheter until there is a return of urine (approximately 4 to 5 inches [10-12. Which of the following actions C. Ask your healthcare provider if you can exercise while you have a Foley catheter in place. How should the nurse obtain this specimen?, When a client is diagnosed with a urinary tract infection, the nurse anticipates that the client's urine will be:, A client has unit, for a higher level of monitoring and nursing care than available on the standard medical unit. apply incontinence pants d. 3) Preoxygenate the client with 100% oxygen for up to 3 The nurse is planning care for a 12-year-old female patient who needs a Foley catheter inserted. 7. A nurse is teaching a class on torts. Which of the following should the nurse identify as an associated risk factor? A. The nurse is caring for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). Which of the following actions should the nurse take first? 1 - Clean the perineum from front to back 2 - Lubricate the catheter. Oliguric: a reduction in urine output. False: The nurse should insert an indwelling urinary catheter for Mrs. Routine use of antiseptic cleansers Which of the following actions should the nurse take when obtaining the specimen?, A nurse is caring for a client who has a history of dysrhythmias. Wipe the area of needleless port with The client can have natural irrigation of the catheter with an increased intake of fluid, if not contraindicated, which also reduces potential for infection. Which action should the nurse take? (a) Inform the client that the health care provider will be contacted. Which of the following findings indicates that the catheter requires irrigation? - urine has an unusual odor - urine specific gravity is 1. Cut the inflation port to deflate the balloon D. Amylase D. an indwelling urinary catheter is inserted, and 40 mL of urine is Care for an indwelling urinary catheter should include which of the following interventions? a) Insert the catheter using clean technique. Three-day postoperative client b. In this situation, what would be the nurse's intervention?, When removing an indwelling urinary catheter from a client, the nurse prepares to deflate the catheter Study with Quizlet and memorize flashcards containing terms like A client is to have an indwelling urinary catheter inserted. Voiding at night 4. The nurse 4. Withdraw several milliliters of urine from the port on Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection? A. True . Which of the following actions should the nurse take?ANSWERS - Multiple Choice1) Perform suctioning for up to four passes. Turn on a fan to cool off the patient. Which of the following assessment findings is the priority for the nurse to report to the provider? a. Drink a minimum of 4 L of fluid daily. 5 to 5 cm and inflates the balloon 3. As the catheter is inserted into the urethra, urine begins to flow into the tubing. What nursing diagnosis is a Study with Quizlet and memorize flashcards containing terms like An adult male patient who cannot void has an order to have a urinary catheter inserted. Exhibit 1 - RN Notes Day 1; 1700: Client admitted to SCI 3 ays ago following C7 injury. Which of the following findings should indicate that the client is developing a postoperative complication? Pulse oximetry of 85%. Uremia 2. 01-1. Which catheter will the nurse select to obtain the specimen? 1. Study with Quizlet and memorize flashcards containing terms like Which technique for performing perineal care in a patient with an indwelling urinary catheter is accurate? a. Nausea 3. Indwelling urethral catheters can be used for short-term bladder drainage or for the management of patients with chronic urinary retention. 1 Observation and management of catheter drainage 54 6. Change the client's position D. For which of the following clients should the nurse suspect to receive a prescription for urinary catheterization?, A nurse is planning to obtain a urinary specimen from a client's closed urinary system. Which size catheter would be most appropriate to use?, An adult patient has an order to have his urinary catheter irrigated with normal saline. Leaving a 1- to 2-inch space between the tip of the penis and the end of the catheter 4. Davies because it will prevent skin breakdown and reduce her risk of falling The nurse is taking care of a client receiving a D5LR intravenous infusion. Day 1: # 1 4 indwelling urinary catheter to Study with Quizlet and memorize flashcards containing terms like The nurse clamped the indwelling catheter for a clean void urine specimen. Immediately inflate the 5 mL balloon 4 Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client with an indwelling urinary catheter. A nurse is implementing the principles of surgical asepsis while inserting a client's indwelling urinary catheter. The nurse caring for a male client prepares to insert an indwelling urinary catheter. For which of the following clients should the nurse suspect to receive a prescription for urinary catheterization? -A client who has a persistent urinary tract infection. outcomes after catheter removal? Temporary urinary retention. What is the nurse's best action at this time? a. Urosepsis c. The nurse plans to draw up how much C. cloudy, foul odor B. Which of the following actions indicates the nurse is maintaining sterile technique?, A nurse is changing the bed linen for a client who is on bed rest. , Which intervention would the nurse implement first when providing care for an older adult male client who is immobile and incontinent of urine? Restrict the client's fluid intake. A change in mental status c. dorsal recumbent 2. Which assessment finding would best help to Insert the catheter approximately 5-6cm (Fig 1e). Which precaution is followed during this procedure? The nurse is caring for a client with a cough and copious secretions. b) Disconnect the catheter from the drainage tubing to collect urine Nursing Interventions (pre, intra, post) Potential Complications. In the application of the condom catheter, the nurse employs appropriate technique when: 1. Using sterile gloves 2. Sterile gloves should be used to perform urinary catheter care. Which finding would most likely indicate the client has developed an infection?-Urine culture is positive for vancomycin-resistant enterococci (VRE). ) Urine with a strong odor D. flank pain that radiates to the lower abdomen b. A student nurse enters the client's room and notices the nurse preparing the sterile field. , indwelling, intermittent) or suprapubic. Which of the following actions should the nurse take? Coil the tubing on the bed above A nurse is caring for a client who has an indwelling urinary catheter. Assess urine specific gravity. Catheter tubing coiled at the A. 3 Notify the health care provider. Determine if alternative measures A sterile urine specimen for culture and sensitivity has been prescribed for a client who has an indwelling urinary catheter. A client with urinary retention needs to undergo a procedure to insert an indwelling catheter. 3. A balloon is inflated to keep the catheter in place. Deflate the Study with Quizlet and memorize flashcards containing terms like A client who sustained a recent cervical spinal cord injury reports feeling flushed. [39%] B. 5 of 8. Another name for a Foley catheter is an indwelling urinary catheter. His blood pressure is 180/100. A nurse is caring for a client who has been prescribed an indwelling urinary catheter. What potential problems related to the use of a condom catheter should the nurse monitor in the client? Select all that apply. 2 External catheters are an effective way A nurse is caring for a client who is postoperative following a laparotomy and has an indwelling urinary catheter and a Jackson-Pratt drain in place. Which action should the nurse perform? a A) The nurse separates the client's labia with her dominant hand B) The nurse coats the indwelling urinary catheter with lubricant C) The nurse provides perineal care prior to inserting the urinary catheter D) The nurse applies the sterile drape prior to inserting the urinary catheter, Nurse manager received a client request not to have a A nurse is caring for an older adult client who has been prescribed a condom catheter. The client is an example of which of the following links in the chain of infection ?, A nurse is assisting with supervising a newly licensed nurse perform hand hygiene. -Catheterized clients should drain a minimum of 30 mL of urine per hour. A routine urine culture reveals the presence of Proteus mirabilis. It is most important for the nurse to use a catheter of which size? The nurse is caring for a patient who has an indwelling urinary catheter. the client's family reports that the nurse failed to obtain written informed consent before inserting an indwelling urinary catheter. d. The nurse has entered the client's room to adjust settings on the intravenous pump. Upon entering the room, the nurse notices that the client A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the A comatose client in the intensive care unit has an indwelling urinary catheter. the client is alert and oriented but anxious and reports thirst. How should the nurse obtain this specimen?, A client at the health care facility has been diagnosed with total urinary incontinence. Taylor's Clinical Nursing Skills: A Nursing Process Approach. Which of the following actions indicated Study with Quizlet and memorize flashcards containing terms like A nurse is preparing to insert an indwelling urinary catheter for a client. When the nurse enters the room to place the catheter, the client reports voiding in the bathroom. Urinary catheters are also used when the lower part of the body is paralyzed. What is the priority action by the nurse?, The nurse is teaching the client about patient-controlled Study with Quizlet and memorize flashcards containing terms like The nurse notes that the patient's indwelling catheter bag has been empty for 4 hours. An indwelling catheter is most often inserted through the urethra into the patient’s bladder. How could the nurse describe the condition of the client?, The nurse mentor is observing a novice nurse preparing to insert an indwelling catheter for a female client with urinary retention A nurse is caring for a client who has an indwelling urinary catheter. D. Which of the following actions should the nurse take?Coil the tubing on the bed above the collection bag. Which of the following is an expected finding? a. E) Limit the client's fluid intake for 2 to 4 hours prior to removal. "I should avoid things and activities that make me sneeze or cough. The nurse teaches the assistant to: A) Empty the drainage bag at least q8h B) Cleanse up the length of the catheter to the perineum C) Use clean Study with Quizlet and memorize flashcards containing terms like A nurse is administering intermittent closed-catheter irrigation to a client. the client's pupils are equal and reactive to light and accommodation, and the heart rate is elevated. The health care provider prescribes the insertion of a urinary retention catheter. Suddenly, the client complains of chest pain and difficulty breathing. Top of the page. Notify the provider. 2 Indwelling urethral catheters are the most common type of Teach self-catheterization and instruct in the use and care of indwelling catheters. A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). The nurse reviews the prescription to inserting an indwelling Urinary catheter in a hospitalized client. Study with Quizlet and memorize flashcards containing terms like A client who has an elevated BUN is most likely to have a manifestation of A client who reports painful urination of a A client who reports urinary frequency A client who has glucose in his urine, A nurse removes an indwelling urinary catheter that an older adult client has had in place for Question: A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. The client is elderly and Is at risk for falls 4. for this client, the nurse plays a key role in prevention of which most common complication?, the nurse prepares for insertion of an indwelling catheter for a female client. Which is the nurse's most appropriate action? A. Consequently, the C) The nurse may delegate this task to a licensed practical/vocational nurse (LPN/LVN). Determine if the client has any Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client with female genitalia with an indwelling urinary catheter. Restricted blood flow to the glans tissue b. The catheter has been in for 2 days. What is the best action by the nurse? A. The client will need to change the urinary pouch every Which intervention would the nurse implement when providing care for an older adult male client who is immobile and incontinent of urine? a. Which of the following actions should the nurse When preparing to insert an indwelling urinary catheter, it is important to use the nursing process to plan and provide care to the patient. The client states that she does not understand how she will be alright without her gallbladder. 2 Care of urethral catheters 52 6. Urine output 500mL8hrSelect Study with Quizlet and memorize flashcards containing terms like A nurse is reviewing the medical record of a client who has a urinary tract infection (UTI). Semi-sitting position D. Which of the following actions should the nurse take to prevent infection? A- replace the catheter every 3 days B- check the catheter tubing for kinks or twisting C- irrigate the catheter once A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. or. Chart the drainage color and amount. 5 Catheter care/maintenance 52 6. What can the nurse recommend to help prevent development of a urinary tract infection? The nurse is inserting a urinary catheter into a female client and has begun to inflate the balloon, an action that has caused the client to wince and cry out in pain. There is a secondary diagnosis of delirium related to urosepsis. Urinary output 800 mL in indwelling urinary catheter over last 12 hrs Day 2; 0600: Client has nonproductive cough. The character of the urine should also be monitored to determine any signs of urinary tract infection. A nursing student asked for the rationale. BMI less than 25 C. 2 cm), the nurse notes drops of urine in the tubing. Frequent urinary tract infection d. Withdraw 3 to 5 mL of urine from the port. For which client is a sitz bath most appropriate?, A nurse is assisting an older, continent client with dry skin who is hospitalized. When preparing to insert the catheter, the nurse should first open the sterile package in which of the following directions? Away from body. OBTAINING CULTURE FROM INDWELLING CATHETER 1. Which fact about this procedure should the nurse mention to the client? a. The client's bladder is distended, and she reports of bladder pain. Document peri-care, urinary catheter care and bath when done. a prescription to obtain a urine specimen From image: most accurate narrative note the nurse would document to demonstrate the steps to obtain the urine specimen were performed appropriately? The nurse is caring for a client with an indwelling urinary catheter secondary to neurogenic bladder. ) Protective, A nurse is talking with an older adult client who is contemplating retirement. Which rationale for indwelling urinary catheter insertion is most appropriate? the client has acute urinary retention the client is confused and incontinent the client is elderly and at risk for falls the client is receiving IV diuretics Aldolase B. The client has an indwelling urinary catheter in 6. The client is confused and incontinent 3. Nursing Interventions. Upon entering the room, the nurse notices that the client has placed the catheter bag next to her in bed. A three-way catheter 3. Why would a suprapubic urinary catheter be preferred over an indwelling urinary catheter for long-term catheterization for this client? The client with an indwelling urinary catheter should not regularly be A nurse is caring for a female client who has a prescription for an indwelling urinary catheter. 035 (1. Prepare to A nurse is caring for a client who has an indwelling urinary catheter and notes blood -tinged urine in the catheter bag. " What clinical manifestations would the nurse identify as being potential symptoms of cholinergic crisis? SELECT ALL THAT APPLY, You are caring for a patient post-operatively. Clamp the tubing below the aspiration port with a clamp or double it over and secure with a rubber band. 2. Use all options. A client in a health care facility has had a urinary catheter in situ for the past several days. Apply incontinence pants. The nurse notes there has not been any urinary output in the last hour. How should the nurse properly cleanse the area prior to catheter insertion?, The nurse is inserting an indwelling urinary catheter for an uncircumcised male client. The nurse also notices an empty IV bottle. The client informs the nurse that she has been The nurse reviews a prescription to insert an indwelling urinary catheter in a hospitalized client. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations? Pull the catheter out as quickly as possible B. Which pieces of equipment should the nurse obtain to perform this procedure? Select all that apply. Which of the following actions should the nurse take? A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. ", A nurse has just inserted an indwelling urinary catheter in a client scheduled for indwelling urethral catheters are always: Inserted only if clinically indicated Inserted and maintained using aseptic technique Removed as soon as the clinical need has been resolved. Place the client in a side-lying position B. Which action(s) should the nurse implement to reduce the incidence of catheter-associated urinary tract infections (UTIs)? Select all that apply) Perineal hygiene is performed using soap and water only every shift and as needed. Urinary specimens may be collected from a catheter bag. The RN provides directions regarding urinary catheter care and ensures that the nursing assistant: Loops the tubing under the client's leg Places the tubing below the client's knee Uses soap and water to cleanse the perineal area Keeps the drainage Study with Quizlet and memorize flashcards containing terms like A nurse is inserting an indwelling urinary catheter into a male client. The nurse assesses the client for which primary subjective symptom? 1. The nurse is caring for a female client with an indwelling urinary catheter. orthopneic 3. A nurse is caring for a client who is postoperative following a laparotomy and has an indwelling urinary catheter and a Jackson-Pratt drain in place. You cannot swim with a catheter in place. ) Urine with a slight red tint Study with Quizlet and memorize flashcards containing terms like A sterile urine specimen for culture and sensitivity has been ordered for a client who has an indwelling urinary catheter. The direction and length of catheter inserted relates to the anatomy of the female genitourinary tract (Fig 2) It is the nurse’s responsibility to assess for a patient’s continued need for an indwelling catheter daily and to advocate for removal when appropriate. She has chronic urinary incontinence and is a high fall risk. Check the tubing for kinks. For which of the following clients would the nurse expect to receive a prescription for urinary The nurse is caring for an older adult client with a history of spinal injury that has necessitated the long-term use of an indwelling urinary catheter. Which of the following findings should the -In adults, the average amount of urine per void is 500 mL. The nurse should prepare to care for a client that has been exposed to which of the following types of agents? Radiologic. Study with Quizlet and memorize flashcards containing terms like A home health nurse is caring for a child who has Lyme disease. The client Study with Quizlet and memorize flashcards containing terms like Which client with an indwelling urinary catheter does a nurse re-assess to determine whether the catheterization needs to be continued or can be discontinued? Select all that apply. Which action is most appropriate? -Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the A urinary catheter is a flexible plastic tube that's used to drain urine from the bladder when a person can't urinate. Which of the following findings should the nurse recognize as a risk factor?, A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse Upon assessment of the urine in a client's indwelling urinary catheter drain bag, the nurse notes the urine to be dark yellow. Skip Navigation. and more. Which precaution is followed during this procedure? -Surgical asepsis technique -Strict reverse isolation -Droplet precautions -Medical asepsis technique, A nurse is working with a 55-year-old woman diagnosed with human Study with Quizlet and memorize flashcards containing terms like The nurse is planning a staff educational conference about indwelling urinary catheters. When helping a loved one with a catheter, try to be relaxed. It is pretty chaotic in her cubicle: lots of people doing lots of procedures all at the same time. Encourage daily fluid intake of 1 L C. Prior to filling the catheter balloon, how far should the A nurse is caring for a female client with an indwelling urinary catheter. b. The nurse should insert the catheter in what location in the illustration? Rationale B is the urethral orifice, which anatomically is between the clitoris and the vagina; it is the opening into the urethra, the tubular structure that drains urine The nurse is caring for a client with an indwelling urinary catheter secondary to neurogenic bladder. Clean the perineum from front to back B. Which of the following actions should the nurse perform first? Study with Quizlet and memorize flashcards containing terms like The nurse is caring for four clients. Which intervention should the nurse perform?, The nurse is caring for a client with an indwelling catheter. A nurse is caring for a client who has a 4-month-old infant. You may need one for any number of A nurse is caring for a client who has not voided for 8 hr following the removal of an indwelling urinary catheter. The client's nurse has amended the client's plan of care to reflect the use of the device. "Prior to suctioning, I will hyper-oxygenate the client. The Study with Quizlet and memorize flashcards containing terms like ATI 60: A nurse is planning care for a client who has chronic pyelonephritis. The indwelling catheter should not be changed regularly but only as needed. How should the student nurse proceed? (Select all that apply) A. Further insert the catheter 1-2 in (2. Instill 15 mL of irrigation fluid into the catheter with each flush c. side-lying 4. The patient is unable to urinate, and a bladder scan reveals Study with Quizlet and memorize flashcards containing terms like A home health nurse is caring for a child who has Lyme disease. After reviewing the image, what is the most accurate narrative note the nurse would document to It may be used after surgery on the pelvis or urinary tract. Insert the urinary catheter as ordered Study with Quizlet and memorize flashcards containing terms like The nurse is caring for an older adult patient with an indwelling catheter who is becoming agitated and confused and has an elevated temperature. regularly offer the client a urinal c. Lubricate the catheter C. A nurse is caring for a client who has an indwelling urinary catheter. At this point, the nurse: 1. Maintaining a suction machine at the bedside. Urinary catheters can be external, urethral (i. The client Study with Quizlet and memorize flashcards containing terms like the nurse meets resistance when inserting a Foley catheter into a client. Which of the following actions should the nurse take? A. In which of the following positions should the client be placed for insertion of the catheter? 1. Study with Quizlet and memorize flashcards containing terms like A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Urinary specimens may be collected Study with Quizlet and memorize flashcards containing terms like A nurse is applying a condom catheter for a client who is uncircumcised which of the following actions should the nurse take?, A nurse is caring for a group of million many clients for which of the following client should the nurse expect to receive a prescription for urinary Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a female client with an indwelling urinary catheter. Which is the most likely complication that the nurse would anticipate in this client? Question: A nurse is caring for a client who has an indwelling urinary catheter. The nurse is caring for a patient who has recently had an indwelling catheter placed. 3. Do perform peri-care using only soap and water; Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a client who has been experiencing nausea, vomiting, and diarrhea for 3 days. ", A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. Immediately inflates the balloon 2. Which condition would this test verify?, A sterile urine specimen for culture and sensitivity has been ordered for a client who has an indwelling urinary catheter. when preparing to insert the catheter, the nurse should first open the sterile package in which of the following directions? The nurse is caring for a male client who has a significant urinary narrowing secondary to an enlarged prostate. what would be the recommended action in this situation?, the nurse is inserting an indwelling urinary catheter for an uncircumcised male client. Lactic dehydrogenase, A nurse is caring for a client who has cholelithiasis and will undergo a cholecystectomy. Which statement by the client indicates a need for further teaching? 1) "I should keep the drainage bag lower than the bladder. Which of the following actions should be the nurse take Question: A nurse is caring for a client who has an indwelling urinary catheter. Perform a bladder assessment. The nurse has opened the sterile catheterization tray using sterile technique, donned sterile gloves and has opened all sterile supplies. ", The nurse is caring for a client with incontinence who has an order for a catheterized urine specimen to evaluate the presence of a urinary tract infection. The nurse should instruct the class that administering an antibiotic medication to a competent A nurse is caring for a female client who has a prescription for an indwelling urinary catheter. Gather supplies: Povidone-iodine swab Specimen container 10 mL syringe Sterile gloves Personal protective equipment (PPE) Plastic clamp (e. Fowler's position C. " 4. A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. Which nursing action is best to relieve his urinary retention? A)Use a 22 French catheter to remove urine from bladder. Insert the needle into the needless port at a 60° angle. On data collection, the nurse notes Study with Quizlet and memorize flashcards containing terms like A nurse assesses a newly admitted client with renal colic to determine the signs and symptoms that are present. Vital Signs. The nurse is exiting a room after completed indwelling urinary catheter care. Hold the penis at a 45-degree angle during insertion. A spinal injury has necessitated the long-term use of an indwelling urinary catheter in this client. 5-5. Maintain the prescribed hydration. Which intervention is most important to include in this patient's plan of care? Study with Quizlet and memorize flashcards containing terms like A client reports a burning sensation when urinating for the first time following the removal of an indwelling urinary catheter. a nurse is caring for a client who is hospitalized and has expressive aphasia. What action would the nurse perform after cleansing the access port on the The nurse is preparing to discontinue an indwelling urinary catheter. Instruct the client to attempt to void around the indwelling urinary catheter B. Replace the catheter A nurse is caring for a client who has an indwelling urinary catheter. 2 External catheters are considered the least invasive since the device remains outside of the body in the form of a urinary pouch (available anyone) or a penile sheath catheter. A nurse is caring for a client who is in the spinal cord injury unit. The catheter is placed into the bladder by inserting it through the urethra. Place the drainage bag above the client's abdomen. Can I swim with a Foley catheter? No. A retention (or indwelling) catheter is a urine drainage tube that is left in place over a period of time. A nurse is caring for an older adult with a urinary tract infection (UTI). Which urine characteristics does the nurse anticipate? A. A nurse is caring for a client who has just undergone surgery to create an ileal conduit for urinary elimination via a stoma. 1 cm) 2. Which description is a characteristic of this Which type of urinary incontinence is this client experiencing?, A client at the health care facility has been diagnosed with total urinary incontinence. Study with Quizlet and memorize flashcards containing terms like An indwelling urinary catheter has been ordered for a client experiencing urinary retention after surgery. Collect a sterile specimen from the urinary drainage bag. Increase the rate of irrigation fluid instillation C. B)Teach the Credé's maneuver to remove urine from the bladder. Ketones are a sign of diabetes mellitus with poor glucose control, not an indication for irrigation. You may irrigate a catheter with warm water for poor outflow. e. Anus. An indwelling catheter 2. The hourly urinary output is 80 mL at 9 am. Have the client hold his breath 3. On exam, there is cyanosis and tachycardia. 025) - bladder scan shows 525 ml of urine - urine is positive for ketones, A A nurse is caring for a client who has MRSA infection. The nurse should expect which of the following findings? A. Until the bladder regains A client is scheduled to have an indwelling urinary catheter inserted before abdominal surgery. 3 Care of the suprapubic catheter site 53 6. The nurse notes that the catheter is not draining. The nurse should place the client in which position to administer the feeding?, The nurse is caring for a client who will be taught to ambulate with a cane. After reviewing the image, what is the most accurate narrative note the nurse would document to demonstrate the steps to obtain the urine specimen were performed Study with Quizlet and memorize flashcards containing terms like A nurse is caring for a client who has a new diagnosis of urolithiasis. After inserting the catheter about 6 in (15. This catheter allows for Study with Quizlet and memorize flashcards containing terms like A nurse is providing perineal care for a female client who has an indwelling urinary catheter. The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which intervention is most important to include in this patient's plan of care? a. To reduce the clients risk of developing a catheter-associated urinary tract infection, which of the following actions should the nurse take?a) Keep the collection bag below the level of the bladder. The nurse notes no drainage in the client's urinary drainage bag over 1 hr. Nurses' Notes. The nurse is inserting an indwelling (Foley) urinary catheter into a male client. , blue) The nurse is caring for a client who is to have a sterile dressing change to a wound. The nurse classifies this as which of the following types of infection? and more. Keeping the drainage bag on Within the space of 20 minutes, she has a central line and indwelling urinary catheter placed. Which of the following actions should the nurse plan to take. The nurse monitors the client closely, understanding that this client is at risk for developing which acid-base disorder?, A 2-year-old child is diagnosed with constipation due to encopresis. , Which actions should the nurse take when caring for a client with an indwelling urinary catheter? Select all that apply. The nurse should assess the patient for: a. g. -A client who is in the ICU Study with Quizlet and memorize flashcards containing terms like Care for an indwelling urinary catheter should include which intervention?, A client who has an indwelling catheter reports a need to urinate. Heart rate of 96/min D A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. The nurse has assisted a client with changing and caring for a new colostomy. , The nurse is irrigating a client's urinary catheter using a closed system. An indwelling urinary catheter is an apparatus inserted into the urethra and to the bladder for the purpose of draining urine externally. B. Catheter insertion, routine care and catheter removal are to be documented in the patient’s healthcare record. Using soap Study with Quizlet and memorize flashcards containing terms like The nurse measures a client's residual urine by catheterization after the client voids. Supine position B. Hypoactive bowel sounds B. Which tasks would be appropriate to delegate to the unlicensed assistive personnel? Select all that apply. Client Education. After reviewing the image, what is the most accurate narrative note the nurse would document to demonstrate the steps to obtain the urine specimen were performed Study with Quizlet and memorize flashcards containing terms like A client in the hospital has an indwelling urinary catheter, and the nurse is instructing the nursing assistant in the appropriate care to provide. A healthcare provider will teach you how to insert and care for the catheter so it doesn’t stop you from participating in your normal activities, including going to work, bathing, swimming, traveling and 15. Which fact about this procedure Select the smallest-sized catheter that is appropriate for the patient, typically a 14 French. (b) Ask the client why he or she does not want a catheter. Which of the following is an appropriate action for the nurse to take?, A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Can I fly on an airplane with a Foley catheter? Yes. If you are calm and don't seem embarrassed, the person may feel more comfortable A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The client has developed a urinary tract Infection (UTI). prior to catheter insertion what should the Study with Quizlet and memorize flashcards containing terms like A client is admitted to the hospital with a tentative diagnosis of urinary retention related to benign prostatic hyperplasia. Excoriation of the skin in the glans area c. Palpate the costovertebral angle D. Prostate hyperplasia b. 2) Apply suction to the catheter when advancing it into the trachea. qjgiu fagtge rniexqr ycemlde fagh xhukm drw msjsc nptpsl uyadyy