Week 1 Flashcards
Steps for Inserting a catheter into the vagina
- drape patient and place waterproof pad under patient
- place in dorsal recumbant position (flat on back with legs frogged)
- Clean perineum and identify the patients urinary meatus
- create sterile field from pre-packaged kit
- place drape between patients legs
- don sterile gloves
- place sterile drape over perineum
- lubricate the catheter and set aside in sterile field
- cleanse patients urethra meatus. your hand is now contaminated. wipe outer to inner do not allow labia to close
- insert catheter, when you see urine advance another 1-2 inches. hold in place and insert syringe to inflate the balloon
- secure to leg
Catheter teach back
- Use call light to get up
- keep area clean
- keep bag below bed level
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.
C. Use the smallest-size catheter possible.
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
A. Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based substances
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.”
A. “Please direct the light to better illuminate the patient’s perineal area.”
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.
C. Remove soiled gloves, and perform hand hygiene.
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.
C. Reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip.
placing a catheter in a penis
- drape patient and place waterproof pad under patient
- place in supine position with legs slightly abducted
- Clean perineum and identify the patients urinary meatus
- create sterile field from pre-packaged kit
- place drape between patients legs
- don sterile gloves
- place sterile drape over perineum
- lubricate the catheter and set aside in sterile field
- cleanse the penis. your hand is now contaminated. move in circular strokes starting at the meatus and spirally out
- insert catheter, when you see urine advance another to the bifurcation. hold in place and insert syringe to inflate the balloon. pull catheter out until you feel resistance
- secure to leg
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
D. To promote relaxation
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.
C. Lubricate the first 5 to 7 inches of the 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 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.
B. The excess catheter tubing has been coiled beside the patient’s inner thigh.
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.
C. Clean the urinary meatus daily.
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.
C. Replace all contaminated supplies, and begin the process again.
order of donning PPE
- Gown
- Mask
- Googles or shield
- gloves
removal of PPE
- gloves
- eyewear
- gown
- mask
Which personal protective equipment (PPE) will the nurse wear if there is a risk of a blood splash when caring for a patient?
A. Gown
B. Gown and gloves
C. Gown, gloves, and mask
D. Gown, gloves, mask, and eye protection
D. Gown, gloves, mask, and eye protection
What will the nurse do first when preparing to apply personal protective equipment (PPE) before caring for a patient in isolation?
A. Perform hand hygiene
B. Put on the gown
C. Put on clean gloves
D. Apply eyewear
A. Perform hand hygiene
The nurse is discussing the guidelines for proper use of PPE by nursing assistive personnel (NAP). Which statement made by the NAP requires follow-up by the nurse?
A. “When in doubt, I wear gloves.”
B. “I really dislike wearing a mask, so it’s the first thing I take off.”
C. “I always do hand hygiene when entering and leaving a patient’s room.”
D. “I wear a mask whenever I am caring for a patient who’s coughing.”
B. “I really dislike wearing a mask, so it’s the first thing I take off.”
When removing a gown worn as personal protective equipment (PPE) while caring for a patient in isolation, why does the nurse avoid touching the outside of the gown?
A. To ensure that the gown can be reused
B. To protect the nurse’s uniform
C. To prevent touching contaminated material with unprotected hands
D. To fold the gown correctly for reuse by the same nurse
C. To prevent touching contaminated material with unprotected hands
When delegating patient care that requires nursing assistive personnel (NAP) to use personal protective equipment (PPE), it is necessary for the nurse to do what first?
A. Discuss what equipment and supplies to bring to the patient’s room
B. Document that the care was delegated to the NAP
C. Review the patient’s need for a specific isolation precaution
D. Observe the NAP donning the appropriate PPE
C. Review the patient’s need for a specific isolation precaution
A nurse is assessing a patient’s neck with the patient seated. Which of the following is considered an unexpected finding?
A. Jugular vein distention
B. Midline trachea
C. Lack of bruits in carotid arteries
D. Thyroid symmetry bilaterally
A. Jugular vein distention
A nurse is inspecting the patient’s ears with an otoscope. Which of the following findings would be considered normal?
A. A small plastic bead
B. Brownish black tympanic membrane
C. Perforation of the tympanic membrane
D. Small amount of cerumen
D. Small amount of cerumen
In which arteries are bruits considered normal?
A. Carotid arteries
B. Temporal arteries
C. Aortic artery
D. None of the above
D. None of the above
Neck rotation on each side should be:
A. 120 degrees
B. 70 degrees
C. 10 degrees
D. 45 degrees
B. 70 degrees
