NURS 104L Fundamentals of Nursing: Catheterization & Urinary Care
(2026/2027) WCU
1. When inserting an indwelling urinary catheter in a female patient, the nurse
notices that the catheter has entered the vaginal opening instead of the meatus.
What should the nurse do next?
A. Leave the catheter in the vagina as a landmark and obtain a new sterile kit.
B. Remove the catheter and reinsert it into the meatus.
C. Wipe the catheter with an antiseptic swab and reposition it.
D. Ask the patient to bear down and push the catheter further in.
Answer: A
Rationale: Leaving the catheter in the vagina prevents the nurse from re-entering the
same wrong opening and acts as a landmark; a new sterile kit is required to ensure the
urinary tract is not contaminated by vaginal flora.
2. Which clinical indicator is the most reliable sign that a patient is experiencing
urinary retention rather than a decrease in urine production?
A. A bladder scan reveals 450 mL of urine in the bladder after voiding.
B. The patient has not voided for 8 hours but reports no discomfort.
C. The patient’s blood urea nitrogen (BUN) levels are elevated.
D. The patient exhibits dark, concentrated amber-colored urine.
Answer: A
Rationale: A bladder scan measures post-void residual (PVR); high volumes (e.g., >300
mL) indicate retention, whereas low output with an empty bladder would suggest a
production issue such as dehydration or renal failure.
,3. During the insertion of a catheter in a male patient, the nurse meets
resistance at the prostatic sphincter. What is the priority nursing action?
A. Force the catheter through the resistance to ensure it reaches the bladder.
B. Stop the procedure and notify the healthcare provider immediately.
C. Withdraw the catheter and try a smaller size.
D. Have the patient take deep breaths and apply gentle, steady pressure.
Answer: D
Rationale: Gentle pressure and deep breaths help relax the external sphincter; if resistance
persists, the nurse should stop, but initial nursing interventions involve techniques to
promote muscle relaxation.
4. To maintain the sterility of the urinary drainage system, which action by the
nurse is correct?
A. Disconnect the catheter from the drainage tube to collect a sterile specimen.
B. Keep the drainage bag below the level of the bladder at all times.
C. Place the drainage bag on the patient’s bed during transport.
D. Empty the drainage bag every 24 hours regardless of volume.
Answer: B
Rationale: Keeping the bag below the bladder level prevents the backflow (reflux) of
contaminated urine into the bladder, which is a primary cause of CAUTI.
5. A nurse is preparing to perform a sterile catheterization. After cleaning the
labia with antiseptic, the nurse’s non-dominant hand slips and closes over the
labia. What must the nurse do?
A. Continue the procedure quickly before bacteria can migrate.
B. Re-clean the area using the remaining antiseptic swabs.
C. Discard the entire kit and start the procedure over.
D. Use the dominant hand to re-open the labia and proceed.
Answer: B
, Rationale: If the labia close after cleaning, the area is contaminated. The nurse must re-
clean the area. If no more swabs are available, a new kit would be needed, but the
immediate clinical step is re-cleansing.
6. Which of the following patients has the most appropriate indication for the
placement of an indwelling urinary catheter?
A. A patient who is undergoing a prolonged surgical procedure with large fluid volume infusion.
B. A patient who is incontinent and has a high risk for skin breakdown.
C. A patient who is too weak to use a bedpan or walk to the bathroom.
D. A patient who requires a 24-hour urine collection for creatinine clearance.
Answer: A
Rationale: Prolonged surgery with large fluid shifts is a legitimate indication. Incontinence,
weakness, and specimen collection should be managed with non-invasive methods first
according to CAUTI prevention guidelines.
7. When inflating the balloon of an indwelling catheter, the patient complains of
sharp, sudden pain. What is the nurse’s best response?
A. Tell the patient that the pain is expected and will subside shortly.
B. Finish the inflation quickly to minimize the duration of the pain.
C. Stop the inflation, aspirate the fluid, and advance the catheter further.
D. Remove the catheter immediately and notify the physician.
Answer: C
Rationale: Pain during balloon inflation usually indicates the balloon is in the urethra
rather than the bladder. The nurse should deflate the balloon, advance the catheter further
into the bladder, and then re-attempt inflation.
(2026/2027) WCU
1. When inserting an indwelling urinary catheter in a female patient, the nurse
notices that the catheter has entered the vaginal opening instead of the meatus.
What should the nurse do next?
A. Leave the catheter in the vagina as a landmark and obtain a new sterile kit.
B. Remove the catheter and reinsert it into the meatus.
C. Wipe the catheter with an antiseptic swab and reposition it.
D. Ask the patient to bear down and push the catheter further in.
Answer: A
Rationale: Leaving the catheter in the vagina prevents the nurse from re-entering the
same wrong opening and acts as a landmark; a new sterile kit is required to ensure the
urinary tract is not contaminated by vaginal flora.
2. Which clinical indicator is the most reliable sign that a patient is experiencing
urinary retention rather than a decrease in urine production?
A. A bladder scan reveals 450 mL of urine in the bladder after voiding.
B. The patient has not voided for 8 hours but reports no discomfort.
C. The patient’s blood urea nitrogen (BUN) levels are elevated.
D. The patient exhibits dark, concentrated amber-colored urine.
Answer: A
Rationale: A bladder scan measures post-void residual (PVR); high volumes (e.g., >300
mL) indicate retention, whereas low output with an empty bladder would suggest a
production issue such as dehydration or renal failure.
,3. During the insertion of a catheter in a male patient, the nurse meets
resistance at the prostatic sphincter. What is the priority nursing action?
A. Force the catheter through the resistance to ensure it reaches the bladder.
B. Stop the procedure and notify the healthcare provider immediately.
C. Withdraw the catheter and try a smaller size.
D. Have the patient take deep breaths and apply gentle, steady pressure.
Answer: D
Rationale: Gentle pressure and deep breaths help relax the external sphincter; if resistance
persists, the nurse should stop, but initial nursing interventions involve techniques to
promote muscle relaxation.
4. To maintain the sterility of the urinary drainage system, which action by the
nurse is correct?
A. Disconnect the catheter from the drainage tube to collect a sterile specimen.
B. Keep the drainage bag below the level of the bladder at all times.
C. Place the drainage bag on the patient’s bed during transport.
D. Empty the drainage bag every 24 hours regardless of volume.
Answer: B
Rationale: Keeping the bag below the bladder level prevents the backflow (reflux) of
contaminated urine into the bladder, which is a primary cause of CAUTI.
5. A nurse is preparing to perform a sterile catheterization. After cleaning the
labia with antiseptic, the nurse’s non-dominant hand slips and closes over the
labia. What must the nurse do?
A. Continue the procedure quickly before bacteria can migrate.
B. Re-clean the area using the remaining antiseptic swabs.
C. Discard the entire kit and start the procedure over.
D. Use the dominant hand to re-open the labia and proceed.
Answer: B
, Rationale: If the labia close after cleaning, the area is contaminated. The nurse must re-
clean the area. If no more swabs are available, a new kit would be needed, but the
immediate clinical step is re-cleansing.
6. Which of the following patients has the most appropriate indication for the
placement of an indwelling urinary catheter?
A. A patient who is undergoing a prolonged surgical procedure with large fluid volume infusion.
B. A patient who is incontinent and has a high risk for skin breakdown.
C. A patient who is too weak to use a bedpan or walk to the bathroom.
D. A patient who requires a 24-hour urine collection for creatinine clearance.
Answer: A
Rationale: Prolonged surgery with large fluid shifts is a legitimate indication. Incontinence,
weakness, and specimen collection should be managed with non-invasive methods first
according to CAUTI prevention guidelines.
7. When inflating the balloon of an indwelling catheter, the patient complains of
sharp, sudden pain. What is the nurse’s best response?
A. Tell the patient that the pain is expected and will subside shortly.
B. Finish the inflation quickly to minimize the duration of the pain.
C. Stop the inflation, aspirate the fluid, and advance the catheter further.
D. Remove the catheter immediately and notify the physician.
Answer: C
Rationale: Pain during balloon inflation usually indicates the balloon is in the urethra
rather than the bladder. The nurse should deflate the balloon, advance the catheter further
into the bladder, and then re-attempt inflation.
