NURS2106 TEST QUESTIONS AND ANSWERS A+
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what is a bladder scan used for?
to assess bladder volume non-invasively and to determine the amount of urine retention
or post-void urine retention
what are the risks associated with catherterisation?
- risks of UTI from the introduction of microorganisms into the bladder
- for males whose urethra is longer, causes trauma to the urethra due to forced insertion
or at an incorrect angle
describe 3 main types of catheters
1. straight catheters which are inserted to drain the bladder. Use if only a spot urine
specimen is needed, if residual urine needs to be measured, or if temporary
decompression/ emptying of the bladder is required
2. indwelling/retention catheters. Use if the bladder is to remain empty or if continous
urine measurement/ collection is needed
3. suprapubic catheters. used for those who require continuous or intermittent bladder
irrigation
explain how catheters are sized
catheters are sized by the diameter of the lumen, using the French gauge: the larger the
number, the larger the lumen
outline the reasons for catherterisation
- to relieve discomfort due to bladder distension or to provide gradual decompression of
a distended bladder
- assess the amount of residual urine if the bladder empties incompletely
- obtain a sterile urine specimen
- empty the bladder completely prior to surgery
- facilitate accurate measurement of urinary output for critically ill people whose output
needs to be monitored hourly
- provide for intermittent or continuous bladder drainage and/ or irrigation
- prevent urine from contacting an incision after perineal surgery
explain a closed drainage catheter system
after inserting an indwelling catheter, a closed drainage system is maintained to
minimise the risk of infection
explain how to select an appropriate urinary catheter
the catheter size should be determined by the size of the person's urethral canal
describe the relationship between urinary catheterisation and UTI
the introduction of a catheter through the urethra provides a direct route for
microorganisms. a CAUTI is a symptomatic UTI in a person with a urinary catheter.
bacteria ascend along the outside of the catheter's lumen. The catheter interferes with
the normal voiding mechanism that acts as a defence against organisms entering the
urethra. Local irritation to the urethra or bladder further predisposes tissues to bacterial
invasion
describe the strategies you could use to prevent a UTI
, - follow hand hygiene guidelines
- maintain a closed system
- don't open the drainage system
- if the drainage tube becomes disconnected, do not touch the ends of the catheter or
tubing.
- do not allow the drainage port on the drainage bag to touch the floor
outline what is done differently when catheterising a male patient
When positioning a male patient - help into supine position with thighs slightly abducted
and when draping the patient, drape upper trunk with blanket/ towel, and cover lower
extremities with bed sheets, exposing only genitalia
- for men: take pre-filled syringe of xylocaine gel (2%)
- when applying sterile drape
- when cleaning urethral meatus (different if patient is not circumcised)
- inserting catheter
- anchoring catheter
what are 3 strategies the nurse can employ to promote drainage?
1. maintaining gravity drainage by ensuring that the catheter tube is not kinked
2. encouraging the person to turn from side to side to promote drainage
3. ensuring an adequate fluid intake
The postoperative medical orders include inserting an indwelling urinary catheter
for a female patient. After positioning and prepping the patient, and washing
hands, in what order should the nurse complete this procedure? Place in
chronological order.
- using the non-dominate hand, seperate and clean labia using one swipe per
cotton ball
- remove and dispose of gloves
- apply sterile gloves
- inflate the catheter balloon
- pour cleansing solution over cotton balls
- using the sterile dominant hand, insert catheter 1-2 inches past where urine is
noted in the urethra
1. pour cleansing solution over cotton balls
2. apply sterile gloves
3. using the non-dominate hand, seperate and clean labia using one swipe per cotton
ball
4. using the sterile dominant hand, insert catheter 1-2 inches past where urine is noted
in the urethra
5. inflate the catheter balloon
6. remove and dispose of gloves
A postoperative patient has not passed urine for 5 hours after return to the
surgical unit. Initially the nurse should:
1.
call the doctor
2.
perform a bladder scan to detect volume in bladder
3.
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what is a bladder scan used for?
to assess bladder volume non-invasively and to determine the amount of urine retention
or post-void urine retention
what are the risks associated with catherterisation?
- risks of UTI from the introduction of microorganisms into the bladder
- for males whose urethra is longer, causes trauma to the urethra due to forced insertion
or at an incorrect angle
describe 3 main types of catheters
1. straight catheters which are inserted to drain the bladder. Use if only a spot urine
specimen is needed, if residual urine needs to be measured, or if temporary
decompression/ emptying of the bladder is required
2. indwelling/retention catheters. Use if the bladder is to remain empty or if continous
urine measurement/ collection is needed
3. suprapubic catheters. used for those who require continuous or intermittent bladder
irrigation
explain how catheters are sized
catheters are sized by the diameter of the lumen, using the French gauge: the larger the
number, the larger the lumen
outline the reasons for catherterisation
- to relieve discomfort due to bladder distension or to provide gradual decompression of
a distended bladder
- assess the amount of residual urine if the bladder empties incompletely
- obtain a sterile urine specimen
- empty the bladder completely prior to surgery
- facilitate accurate measurement of urinary output for critically ill people whose output
needs to be monitored hourly
- provide for intermittent or continuous bladder drainage and/ or irrigation
- prevent urine from contacting an incision after perineal surgery
explain a closed drainage catheter system
after inserting an indwelling catheter, a closed drainage system is maintained to
minimise the risk of infection
explain how to select an appropriate urinary catheter
the catheter size should be determined by the size of the person's urethral canal
describe the relationship between urinary catheterisation and UTI
the introduction of a catheter through the urethra provides a direct route for
microorganisms. a CAUTI is a symptomatic UTI in a person with a urinary catheter.
bacteria ascend along the outside of the catheter's lumen. The catheter interferes with
the normal voiding mechanism that acts as a defence against organisms entering the
urethra. Local irritation to the urethra or bladder further predisposes tissues to bacterial
invasion
describe the strategies you could use to prevent a UTI
, - follow hand hygiene guidelines
- maintain a closed system
- don't open the drainage system
- if the drainage tube becomes disconnected, do not touch the ends of the catheter or
tubing.
- do not allow the drainage port on the drainage bag to touch the floor
outline what is done differently when catheterising a male patient
When positioning a male patient - help into supine position with thighs slightly abducted
and when draping the patient, drape upper trunk with blanket/ towel, and cover lower
extremities with bed sheets, exposing only genitalia
- for men: take pre-filled syringe of xylocaine gel (2%)
- when applying sterile drape
- when cleaning urethral meatus (different if patient is not circumcised)
- inserting catheter
- anchoring catheter
what are 3 strategies the nurse can employ to promote drainage?
1. maintaining gravity drainage by ensuring that the catheter tube is not kinked
2. encouraging the person to turn from side to side to promote drainage
3. ensuring an adequate fluid intake
The postoperative medical orders include inserting an indwelling urinary catheter
for a female patient. After positioning and prepping the patient, and washing
hands, in what order should the nurse complete this procedure? Place in
chronological order.
- using the non-dominate hand, seperate and clean labia using one swipe per
cotton ball
- remove and dispose of gloves
- apply sterile gloves
- inflate the catheter balloon
- pour cleansing solution over cotton balls
- using the sterile dominant hand, insert catheter 1-2 inches past where urine is
noted in the urethra
1. pour cleansing solution over cotton balls
2. apply sterile gloves
3. using the non-dominate hand, seperate and clean labia using one swipe per cotton
ball
4. using the sterile dominant hand, insert catheter 1-2 inches past where urine is noted
in the urethra
5. inflate the catheter balloon
6. remove and dispose of gloves
A postoperative patient has not passed urine for 5 hours after return to the
surgical unit. Initially the nurse should:
1.
call the doctor
2.
perform a bladder scan to detect volume in bladder
3.
