NR224 FINAL EXAM TEST BANK VERIFIED
QUESTIONS AND ANSWERS WITH RATIONALES
INCLUDED | 2024-2025 LATEST UPDATE
A pt is scheduled to have an IV pyelogram (IVP) the next morning. Which nursing measures
should be implemented before the test? (select all that apply)
A. Ask the pt about any allergies and reactions
B. instruct the pt that a full bladder is required for the test
C. Instruct the pt to save all urine in a special container
D. Ensure that informed consent has been obtained
E. Explain that the test includes instrumentation of the urinary tract
Answer: A, D
Rationale: AnA IVP involves intravenous injection of an iodine based contrast media. Patients
who have had a previous hypersensitivity reaction to contrast media are at high risk for another
reaction. Informed consent is required. There is no need for a full bladder such as with a pelvic
ultrasound or to save any urine for testing. There is no instrumentation of the urinary tract such
as with a cystoscopy.
When assessing a pt's first voided urine of the day, which finding should be reported to the
health care provider?
A. Pale yellow urine
B. Slightly cloudy urine
C. Light pink urine
D. Dark amber urine
Answer: C
Rationale: Light pink urine indicates the presence of blood in the urine, which is never a normal
finding. First voided urine can be slightly cloudy and darker in color. Pale yellow urine indicates
normal finding.
What is a critical step when inserting an indwelling catheter into a male patient?
A. Slowly inflate the catheter balloon w/sterile saline
B. secure the catheter drainage tubing to the bed sheets
C. Advance the catheter to the bifurcation of the drainage and balloon ports
D. Advance the catheter until urine flows, then insert 1/4 inch more
Answer: C
Rationale: Advancing the catheter to the bifurcation avoids inflating the catheter balloon in the
prostatic urethra, causing trauma and pain. Catheter balloons are never inflated with saline.
Securing the catheter drainage tubing to the bedsheets increases the risk for accidental pulling or
tension on the catheter. Advancing the catheter until urine flows and then inserting it 1 4 inch
more is not unique to the male patient.
, NR224 FINAL EXAM TEST BANK VERIFIED
QUESTIONS AND ANSWERS WITH RATIONALES
INCLUDED | 2024-2025 LATEST UPDATE
Which nursing intervention minimizes the risk for trauma and infection when applying an
external/condom catheter?
A. Leaving a gap of 3-5inches between the tip of the penis ad drainage tube
B. Shaving the pubic area so hair does not adhere
C. Washing with soap and water before applying the condom type catheter
D. Applying tape to the condom sheath to keep it securely in place
Answer: C
Rationale: Hygiene minimizes skin irritation. There needs to be 2.5 to 5 cm (1 to 2 inches) of
space between the tip of the glans penis and the end of the catheter. Excess space may cause
pooling of urine, causing excessive exposure to urine. Shaving the pubic area increases the risk
for skin irritation. The condom should be secure but not tight. Application of tape is
contraindicated because it could interfere with circulation, increasing risk for necrosis of the
penis.
Which instructions should the nurse give the nursing assistive personnel (NAP) concerning a pt
who has had an indwelling urinary catheter removed that day?
A. Limit oral fluid intake to avoid possible urinary incontinence
B. Expect pt complaints of suprapubic fullness and discomfort
C. Report the time and amount of first voiding
D. Instruct pt to stay in bed and use a urinal or bedpan
Answer: C
Rationale: To adequately assess bladder function after a catheter is removed, voiding frequency
and amount should be monitored. Unless contraindicated, fluids should be encouraged. To
promote normal micturition, patients should be placed in as normal a posture for voiding as
possible. Suprapubic tenderness and pain are possible indicators of urinary retention and/or a
urinary tract infection.
A postoperative pt with a three-way indwelling urinary catheter and continuous bladder irrigation
(CBI) complains of lower abdominal pain and distention. What should be the nurse's INITIAL
intervention
A. Increase the rate of the CBI
B. Assess the intake and output from system
C. Decrease the rate of the CBI
D. Assess vital signs
Answer: B
Rationale: An appropriate first action would be to assess the patency of the drainage system.
Urine output in the drainage bag should be more than the volume of the irritant solution infused.
If the system is not draining urine and irrigant, the irrigant should be stopped immediately; the
catheter may be occluded, and the bladder distended.
, NR224 FINAL EXAM TEST BANK VERIFIED
QUESTIONS AND ANSWERS WITH RATIONALES
INCLUDED | 2024-2025 LATEST UPDATE
An ambulatory elderly woman with dementia is incontinent of urine. She has poor short-term
memory and has not been seen toileting independently. What is the BEST nursing intervention
for this pt?
A. Recommend that she be evaluated for an overactive bladder (OAB) medication
B. Start a scheduled toileting program
C. Recommend that she be evaluated for an indwelling catheter
D. Start a bladder-restraining program
Answer: B
Rationale: The first nursing intervention for any patient with incontinence who is able to toilet is
to help him or her with toilet access. This patient is not cognitively intact; therefore a
bladderretraining program is not appropriate for her. It is not clear in this case that she has OAB,
and a catheter is never a good solution for incontinence.
What should the nurse teach a young woman with a history of UTIs about UTI prevention?
(select all that apply)
A. Keep the bowels regular
B. Limit water intake to 1-2 glasses a day
C. Wear cotton underwear
D. Cleanse the perineum from front to back
E. Practice pelvic muscle exercise (Kegel) daily
Answer: A, C, D
Rationale: All are interventions that lead to healthy bladder habits. Adequate hydration will
ensure that the bladder is regularly flushed and will help prevent a UTI. Pelvic muscle exercises
promote pelvic health but do not necessarily prevent UTIs.
Which nursing assessment question would BEST indicate that an incontinent man with a history
of prostate enlargement might not be emptying his bladder adequately?
A. Do you leak urine when you cough or sneeze?
B. Do you need help getting to the toilet?
C. Do you dribble urine constantly?
D. Does it burn when you pass your urine?
Answer: C
Rationale: Incontinence characterized by constant dribbling of urine is associated with
incontinence associated with urinary retention. The other options point to stress incontinence,
functional incontinence, or a urinary tract infection.
Place the following steps for insertion of an indwelling catheter in a female pt in appropriate
order.
1. Insert and advance catheter
, NR224 FINAL EXAM TEST BANK VERIFIED
QUESTIONS AND ANSWERS WITH RATIONALES
INCLUDED | 2024-2025 LATEST UPDATE
2. Lubricate catheter
3. Inflate catheter balloon
4. Cleanse urethral meatus with antiseptic solution
5. Drape pt with the sterile square and fenestrated drapes
6. When urine appears, advance another 2.5-5cm
7. Prepare sterile field and supplies
8. Gently pull catheter until resistance is felt
9. Attach drainage tubing
Answer: 5, 7, 2, 4, 1, 6, 3, 8, 9
The nursing assistive personnel (NAP) reports to the nurse that a pt's catheter drainage bag has
been empty for 4 hours. What is a priority nursing intervention?
A. Implement the "as-needed" order to irrigate the catheter
B. Assess the catheter and drainage tubing for obvious occlusion
C. Notify the health care provider immediately
D. Assess the vital signs and intake and output record
Answer: B
Rationale: The priority nursing intervention is to ensure that there is not an occlusion in the
catheter or drainage tubing.
Which nursing interventions should a nurse implement when removing an indwelling urinary
catheter in an adult patient? (select all that apply)
A. Attach a 3 mL syringe to the inflation port
B. Allow the balloon to drain into the syringe by gravity
C. Initiate a voiding record/bladder diary
D. Pull the catheter quickly
E. Clamp the catheter before removal
Answer: B, C
Rationale: By allowing the balloon to drain by gravity, it is possible to avoid the development of
creases or ridges in the balloon and thus minimize trauma to the urethra during withdrawal. All
patients who have a catheter removed should have their voiding monitored. The best way to do
this is with a voiding record or bladder diary. The size syringe used to deflate the balloon is
dictated by the size of the balloon. In the adult patient balloon sizes are either 10 mL or 30 mL.
Catheters should be pulled out slowly and smoothly. There is no evidence to support clamping
catheters before removal.
What best describes measurement of postvoid residual (PVR)?
A. Bladder scan the pt immediately after voiding
B. Catheterize the pt 30 min after voiding
QUESTIONS AND ANSWERS WITH RATIONALES
INCLUDED | 2024-2025 LATEST UPDATE
A pt is scheduled to have an IV pyelogram (IVP) the next morning. Which nursing measures
should be implemented before the test? (select all that apply)
A. Ask the pt about any allergies and reactions
B. instruct the pt that a full bladder is required for the test
C. Instruct the pt to save all urine in a special container
D. Ensure that informed consent has been obtained
E. Explain that the test includes instrumentation of the urinary tract
Answer: A, D
Rationale: AnA IVP involves intravenous injection of an iodine based contrast media. Patients
who have had a previous hypersensitivity reaction to contrast media are at high risk for another
reaction. Informed consent is required. There is no need for a full bladder such as with a pelvic
ultrasound or to save any urine for testing. There is no instrumentation of the urinary tract such
as with a cystoscopy.
When assessing a pt's first voided urine of the day, which finding should be reported to the
health care provider?
A. Pale yellow urine
B. Slightly cloudy urine
C. Light pink urine
D. Dark amber urine
Answer: C
Rationale: Light pink urine indicates the presence of blood in the urine, which is never a normal
finding. First voided urine can be slightly cloudy and darker in color. Pale yellow urine indicates
normal finding.
What is a critical step when inserting an indwelling catheter into a male patient?
A. Slowly inflate the catheter balloon w/sterile saline
B. secure the catheter drainage tubing to the bed sheets
C. Advance the catheter to the bifurcation of the drainage and balloon ports
D. Advance the catheter until urine flows, then insert 1/4 inch more
Answer: C
Rationale: Advancing the catheter to the bifurcation avoids inflating the catheter balloon in the
prostatic urethra, causing trauma and pain. Catheter balloons are never inflated with saline.
Securing the catheter drainage tubing to the bedsheets increases the risk for accidental pulling or
tension on the catheter. Advancing the catheter until urine flows and then inserting it 1 4 inch
more is not unique to the male patient.
, NR224 FINAL EXAM TEST BANK VERIFIED
QUESTIONS AND ANSWERS WITH RATIONALES
INCLUDED | 2024-2025 LATEST UPDATE
Which nursing intervention minimizes the risk for trauma and infection when applying an
external/condom catheter?
A. Leaving a gap of 3-5inches between the tip of the penis ad drainage tube
B. Shaving the pubic area so hair does not adhere
C. Washing with soap and water before applying the condom type catheter
D. Applying tape to the condom sheath to keep it securely in place
Answer: C
Rationale: Hygiene minimizes skin irritation. There needs to be 2.5 to 5 cm (1 to 2 inches) of
space between the tip of the glans penis and the end of the catheter. Excess space may cause
pooling of urine, causing excessive exposure to urine. Shaving the pubic area increases the risk
for skin irritation. The condom should be secure but not tight. Application of tape is
contraindicated because it could interfere with circulation, increasing risk for necrosis of the
penis.
Which instructions should the nurse give the nursing assistive personnel (NAP) concerning a pt
who has had an indwelling urinary catheter removed that day?
A. Limit oral fluid intake to avoid possible urinary incontinence
B. Expect pt complaints of suprapubic fullness and discomfort
C. Report the time and amount of first voiding
D. Instruct pt to stay in bed and use a urinal or bedpan
Answer: C
Rationale: To adequately assess bladder function after a catheter is removed, voiding frequency
and amount should be monitored. Unless contraindicated, fluids should be encouraged. To
promote normal micturition, patients should be placed in as normal a posture for voiding as
possible. Suprapubic tenderness and pain are possible indicators of urinary retention and/or a
urinary tract infection.
A postoperative pt with a three-way indwelling urinary catheter and continuous bladder irrigation
(CBI) complains of lower abdominal pain and distention. What should be the nurse's INITIAL
intervention
A. Increase the rate of the CBI
B. Assess the intake and output from system
C. Decrease the rate of the CBI
D. Assess vital signs
Answer: B
Rationale: An appropriate first action would be to assess the patency of the drainage system.
Urine output in the drainage bag should be more than the volume of the irritant solution infused.
If the system is not draining urine and irrigant, the irrigant should be stopped immediately; the
catheter may be occluded, and the bladder distended.
, NR224 FINAL EXAM TEST BANK VERIFIED
QUESTIONS AND ANSWERS WITH RATIONALES
INCLUDED | 2024-2025 LATEST UPDATE
An ambulatory elderly woman with dementia is incontinent of urine. She has poor short-term
memory and has not been seen toileting independently. What is the BEST nursing intervention
for this pt?
A. Recommend that she be evaluated for an overactive bladder (OAB) medication
B. Start a scheduled toileting program
C. Recommend that she be evaluated for an indwelling catheter
D. Start a bladder-restraining program
Answer: B
Rationale: The first nursing intervention for any patient with incontinence who is able to toilet is
to help him or her with toilet access. This patient is not cognitively intact; therefore a
bladderretraining program is not appropriate for her. It is not clear in this case that she has OAB,
and a catheter is never a good solution for incontinence.
What should the nurse teach a young woman with a history of UTIs about UTI prevention?
(select all that apply)
A. Keep the bowels regular
B. Limit water intake to 1-2 glasses a day
C. Wear cotton underwear
D. Cleanse the perineum from front to back
E. Practice pelvic muscle exercise (Kegel) daily
Answer: A, C, D
Rationale: All are interventions that lead to healthy bladder habits. Adequate hydration will
ensure that the bladder is regularly flushed and will help prevent a UTI. Pelvic muscle exercises
promote pelvic health but do not necessarily prevent UTIs.
Which nursing assessment question would BEST indicate that an incontinent man with a history
of prostate enlargement might not be emptying his bladder adequately?
A. Do you leak urine when you cough or sneeze?
B. Do you need help getting to the toilet?
C. Do you dribble urine constantly?
D. Does it burn when you pass your urine?
Answer: C
Rationale: Incontinence characterized by constant dribbling of urine is associated with
incontinence associated with urinary retention. The other options point to stress incontinence,
functional incontinence, or a urinary tract infection.
Place the following steps for insertion of an indwelling catheter in a female pt in appropriate
order.
1. Insert and advance catheter
, NR224 FINAL EXAM TEST BANK VERIFIED
QUESTIONS AND ANSWERS WITH RATIONALES
INCLUDED | 2024-2025 LATEST UPDATE
2. Lubricate catheter
3. Inflate catheter balloon
4. Cleanse urethral meatus with antiseptic solution
5. Drape pt with the sterile square and fenestrated drapes
6. When urine appears, advance another 2.5-5cm
7. Prepare sterile field and supplies
8. Gently pull catheter until resistance is felt
9. Attach drainage tubing
Answer: 5, 7, 2, 4, 1, 6, 3, 8, 9
The nursing assistive personnel (NAP) reports to the nurse that a pt's catheter drainage bag has
been empty for 4 hours. What is a priority nursing intervention?
A. Implement the "as-needed" order to irrigate the catheter
B. Assess the catheter and drainage tubing for obvious occlusion
C. Notify the health care provider immediately
D. Assess the vital signs and intake and output record
Answer: B
Rationale: The priority nursing intervention is to ensure that there is not an occlusion in the
catheter or drainage tubing.
Which nursing interventions should a nurse implement when removing an indwelling urinary
catheter in an adult patient? (select all that apply)
A. Attach a 3 mL syringe to the inflation port
B. Allow the balloon to drain into the syringe by gravity
C. Initiate a voiding record/bladder diary
D. Pull the catheter quickly
E. Clamp the catheter before removal
Answer: B, C
Rationale: By allowing the balloon to drain by gravity, it is possible to avoid the development of
creases or ridges in the balloon and thus minimize trauma to the urethra during withdrawal. All
patients who have a catheter removed should have their voiding monitored. The best way to do
this is with a voiding record or bladder diary. The size syringe used to deflate the balloon is
dictated by the size of the balloon. In the adult patient balloon sizes are either 10 mL or 30 mL.
Catheters should be pulled out slowly and smoothly. There is no evidence to support clamping
catheters before removal.
What best describes measurement of postvoid residual (PVR)?
A. Bladder scan the pt immediately after voiding
B. Catheterize the pt 30 min after voiding
