Chapter 30: Urinary Elimination
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1. A nurse irrigating a patients indwelling urinary catheter should instill normal saline as
ordered, and then:
a. unclamp the tubing and lower the collection bag.
b. massage the patients bladder.
c. ask the patient to take a deep breath and hold it.
d. keep the tubing clamped for 30 to 45 minutes.
ANS: A
Immediately after irrigating a urinary catheter, the tubing should be unclamped and
the collection bag lowered below the level of the bladder for proper drainage.
DIF: Cognitive Level: Application REF: m 559, Skill 29-5
OBJ: Theory #4 TOP: Irrigation KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological
Integrity: basic care and comfort
2. A nurse is reinforcing instructions about Kegel exercises with a female patient. An
appropriate instruction is to:
a. do the exercises 12 times each day.
b. hold each muscle contraction for a count of 3 seconds.
c. tighten the abdominal muscles.
d. tighten the pelvic muscles.
ANS: D
Kegel exercises involve tightening the pelvic muscles to reduce the likelihood of
urinary incontinence.
DIF: Cognitive Level: Application REF: m 562, Patient Teaching
OBJ: Clinical Practice #7 TOP: Kegel Exercises KEY:
Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity: basic care and comfort
3. A nurse is documenting the removal of a urinary drainage catheter from an assigned
patient. If the catheter is removed at 9:00 AM, the nurse recognizes that the patient is due
to void by:
a. 11:00 AM.
b. 12 noon.
c. 5:00 PM.
d. 9:00 PM.
ANS: C
Documentation of removal of a urinary catheter should include the time the patient is
due to void, which is within 8 hours.
DIF: Cognitive Level: Comprehension REF: m 564 OBJ:
Clinical Practice #1 TOP: Voiding After Urinary Drainage Catheter
Removal KEY: Nursing Process Step: Planning MSC:
, NCLEX: Physiological Integrity: basic care and comfort
4. A patient with a history of cystitis had surgery 24 hours ago and is now unable to void. A
bladder scan indicates that he has approximately 400 mL of retained urine. The nurse
anticipates that the least invasive intervention the physician will order would be:
a. inserting an indwelling Foley catheter.
b. monitoring intake and output.
c. obtaining a midstream specimen.
d. applying Creds maneuver to the bladder.
ANS: D
Creds maneuver is less invasive and may be used before invasive measures are taken.
The bladder is gently massaged from the top of the bladder and rocking the palm of
the hand steadily downward.
DIF: Cognitive Level: Application REF: m 546 OBJ: Clinical
Practice #4 TOP: Plan of Care KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity: basic
care and comfort
5. A nurse is caring for a patient with prostate enlargement who has an indwelling catheter.
As the nurse is attaching a portion of the catheter to the patients abdomen, the patient asks
why this is being done. The correct response is:
a. Taping the catheter to your abdomen will prevent pulling on the meatus.
b. The catheter cant be pulled out if it is taped to your abdomen.
c. Taping it in this way enhances the draining of your bladder.
d. This will prevent the Foley catheter from kinking.
ANS: A
When the catheter is taped to the abdomen, it prevents pulling on the meatus, thus
decreasing irritation.
DIF: Cognitive Level: Comprehension REF: m 552, Skill 29-3
OBJ: Clinical Practice #5 TOP: Catheter Care KEY:
Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity: basic care and comfort
6. A nurse instructing a female patient on obtaining a clean catch urine specimen should
stress to:
a. spread the labia apart and clean the center area first.
b. catch the middle portion of urine after voiding a small amount into the toilet.
c. carefully collect the urine in the container as soon as the urine stream starts.
d. fill the urine cup to the brim to ensure an adequate sample.
ANS: B
The procedure for a midstream or clean-catch urine specimen is to void a small
amount of urine into the toilet and to catch the middle portion of urine by moving the
container into the stream.
DIF: Cognitive Level: Comprehension REF: m 539 OBJ:
Clinical Practice #2 TOP: Clean-Catch Urine Specimen KEY:
Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity: basic care and comfort
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1. A nurse irrigating a patients indwelling urinary catheter should instill normal saline as
ordered, and then:
a. unclamp the tubing and lower the collection bag.
b. massage the patients bladder.
c. ask the patient to take a deep breath and hold it.
d. keep the tubing clamped for 30 to 45 minutes.
ANS: A
Immediately after irrigating a urinary catheter, the tubing should be unclamped and
the collection bag lowered below the level of the bladder for proper drainage.
DIF: Cognitive Level: Application REF: m 559, Skill 29-5
OBJ: Theory #4 TOP: Irrigation KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological
Integrity: basic care and comfort
2. A nurse is reinforcing instructions about Kegel exercises with a female patient. An
appropriate instruction is to:
a. do the exercises 12 times each day.
b. hold each muscle contraction for a count of 3 seconds.
c. tighten the abdominal muscles.
d. tighten the pelvic muscles.
ANS: D
Kegel exercises involve tightening the pelvic muscles to reduce the likelihood of
urinary incontinence.
DIF: Cognitive Level: Application REF: m 562, Patient Teaching
OBJ: Clinical Practice #7 TOP: Kegel Exercises KEY:
Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity: basic care and comfort
3. A nurse is documenting the removal of a urinary drainage catheter from an assigned
patient. If the catheter is removed at 9:00 AM, the nurse recognizes that the patient is due
to void by:
a. 11:00 AM.
b. 12 noon.
c. 5:00 PM.
d. 9:00 PM.
ANS: C
Documentation of removal of a urinary catheter should include the time the patient is
due to void, which is within 8 hours.
DIF: Cognitive Level: Comprehension REF: m 564 OBJ:
Clinical Practice #1 TOP: Voiding After Urinary Drainage Catheter
Removal KEY: Nursing Process Step: Planning MSC:
, NCLEX: Physiological Integrity: basic care and comfort
4. A patient with a history of cystitis had surgery 24 hours ago and is now unable to void. A
bladder scan indicates that he has approximately 400 mL of retained urine. The nurse
anticipates that the least invasive intervention the physician will order would be:
a. inserting an indwelling Foley catheter.
b. monitoring intake and output.
c. obtaining a midstream specimen.
d. applying Creds maneuver to the bladder.
ANS: D
Creds maneuver is less invasive and may be used before invasive measures are taken.
The bladder is gently massaged from the top of the bladder and rocking the palm of
the hand steadily downward.
DIF: Cognitive Level: Application REF: m 546 OBJ: Clinical
Practice #4 TOP: Plan of Care KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity: basic
care and comfort
5. A nurse is caring for a patient with prostate enlargement who has an indwelling catheter.
As the nurse is attaching a portion of the catheter to the patients abdomen, the patient asks
why this is being done. The correct response is:
a. Taping the catheter to your abdomen will prevent pulling on the meatus.
b. The catheter cant be pulled out if it is taped to your abdomen.
c. Taping it in this way enhances the draining of your bladder.
d. This will prevent the Foley catheter from kinking.
ANS: A
When the catheter is taped to the abdomen, it prevents pulling on the meatus, thus
decreasing irritation.
DIF: Cognitive Level: Comprehension REF: m 552, Skill 29-3
OBJ: Clinical Practice #5 TOP: Catheter Care KEY:
Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity: basic care and comfort
6. A nurse instructing a female patient on obtaining a clean catch urine specimen should
stress to:
a. spread the labia apart and clean the center area first.
b. catch the middle portion of urine after voiding a small amount into the toilet.
c. carefully collect the urine in the container as soon as the urine stream starts.
d. fill the urine cup to the brim to ensure an adequate sample.
ANS: B
The procedure for a midstream or clean-catch urine specimen is to void a small
amount of urine into the toilet and to catch the middle portion of urine by moving the
container into the stream.
DIF: Cognitive Level: Comprehension REF: m 539 OBJ:
Clinical Practice #2 TOP: Clean-Catch Urine Specimen KEY:
Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity: basic care and comfort
