Potter: Fundamentals of Nursing, 9th Edition
Answer Key for Urinary Catheterization Module Post Tests and Exam
(Since questions may be reordered with each usage, the question number in the answer key may
not correspon
...
Potter: Fundamentals of Nursing, 9th Edition
Answer Key for Urinary Catheterization Module Post Tests and Exam
(Since questions may be reordered with each usage, the question number in the answer key may
not correspond to the number that the student reports for a particular quiz item).
Lesson 1 Post Test
1. During the change-of-shift report the nurse states that a patient has early renal failure and that
you should be alert to this when administering medications. Why would this be a concern?
a) The kidneys assist in the detoxification of drug metabolites.
b) The patient may not be able to absorb all of the medications.
c) The bladder acts as a filter to remove wastes and form urine.
d) The kidneys are the primary site for drug metabolism.
Correct answer: a
Rationale: The kidneys detoxify and eliminate by products of drug metabolism. If the kidneys
are unable to perform this function, drug toxicity can develop. The nephron, the functional unit
of the kidney, forms the urine. The bladder holds the urine until it is excreted. The liver is a
primary site for drug metabolism.
2. Which of the following demonstrate that further teaching is required to prevent an infection
related to being catheterized? (Select all that apply.)
a) An elderly female carries her urinary drainage bag like a purse under her arm as she
ambulates.
b) A patient drinks an entire pitcher of water over the period of one day.
c) As a patient is being transferred in a wheelchair, he places the drainage bag in his lap.
d) The NAP places a patient’s drainage bag on a lowered side rail or on the floor.
e) A female patient keeps her catheter secured to her thigh with tape.
Correct answer: a, c, d
Rationale: The urinary drainage bag should be kept below the level of the bladder to prevent
reflux of urine into the bladder. Patients should be instructed to carry the drainage bag below the
level of the bladde, and to secure the drainage bag to the side of the wheelchair below the level
of the bladder during transfer. The urinary drainage bag should never be placed on a bedside rail
because it could accidentally be raised to a height higher than the level of the bladder and urine
could reflux into the bladder. The urinary drainage bag should never be placed on the floor; this
is to avoid having bacteria enter the system through the drainage port. If allowed, fluids should
be encouraged. The catheter should be secured to the patient in order to prevent trauma to the
urethra. Swelling of tissues can impair urine flow and place the patient at further risk for urinary
tract infection.
3. Which of the following is (are) true regarding the impact of aging related to urinary
elimination? (Select all that apply.)
a) The elderly are better able to concentrate urine than the middle-aged adult.
b) Aging can affect continence if the patient experiences impaired mobility or decreased
muscle tone.
c) The elderly are less likely to experience urinary frequency than middle-aged adults
because they tend to drink less.
d) The elderly are at increased risk for urinary tract infection (UTI) because of retained
urine in the bladder.
Correct answer: b, d
Rationale: The very young and very old are less able to concentrate urine, thereby placing them
at risk for dehydration. The elderly are at an increased risk of urinary incontinence if they have
impaired mobility that prevents them from getting to the bathroom in time or from manipulating
buttons and zippers. Weak abdominal and pelvic floor muscles impair bladder contraction.
Decreased muscle tone increases the risk for urinary incontinence. Urination frequency increases
with age with decreased bladder tone. Because the bladder cannot contract as effectively, an
older person often retains urine in the bladder after voiding (residual urine). This places the
patient at increased risk for bacterial growth and the development of UTIs.
4. The nursing instructor is reviewing the renal system and urinary catheterization with students.
Which statement, if made by a nursing student, indicates that further instruction is needed?
a) “The urinary tract is considered sterile.”
b) “The nurse may use clean technique to insert an indwelling catheter.”
c) “The urge to void is felt when the bladder contains 150 to 200 mL in an adult.”
d) “The minimum average hourly urine output is 30 mL.”
Correct answer: b
Rationale: Sterile technique is used whether inserting a straight or indwelling urinary catheter.
Patients may use clean insertion technique in the home setting for intermittent catheterization.
When the patient is in an acute or long-term care setting, sterile insertion technique is required
because of the high risk for nosocomial infections. The urinary tract is sterile. The desire to
urinate can be sensed when the bladder contains a smaller amount of urine (150 to 200 mL in an
adult; 50 to 100 mL in a child). The minimum average hourly output is 30 mL.
5. A 53-year-old patient is being treated for hypertension and a history of thrombophlebitis
(blood clots). She comes to the clinic complaining, “I have to get up all night to go to the
bathroom, and I think my urine looks orange!” What is your best response?
a) “It sounds like you may have a urinary tract infection.”
b) “Your high blood pressure is adversely affecting your kidneys.”
c) “How much fluid are you drinking in a day?”
d) “What medications are you taking and when?”
Correct answer: d
Rationale: You should first assess the patient’s medication history before making any
interpretation. The patient may be taking diuretics before going to bed or taking other
medications that can change the urine’s color.
6. A 68-year-old female patient is admitted for knee-replacement surgery with an expected
hospital stay of 2 weeks. She has no known allergies. The physician has ordered an indwelling
Foley catheter to be inserted preoperatively. Which catheter should you choose?
a) 14 French, 5-mL balloon, latex catheter
b) Coude catheter
c) 16 French plastic catheter
d) 18 French, 5-mL balloon, latex catheter
e) 8 French, 3-mL balloon, latex catheter
f) 16 French, 30-mL balloon, silicon catheter
Correct answer: a
Rationale: Women require a 14 to 16 French catheter; it is usually best to begin with the smaller
size. A 5-mL balloon is a common size balloon. Latex and rubber catheters are recommended for
use up to 3 weeks. A Coudé (elbowed and/or curved) catheter is often used for males with
prostatic hypertrophy. Plastic catheters are suitable only for intermittent use because of their
inflexibility. Men require a 16 to 18 French catheter; this would be too large for this patient. Pure
silicon or Teflon catheters are best suited for long-term use (2 to 3 months). The 8-French, 3-mL
balloon, latex catheter is a pediatric catheter.
Lesson 2 Post Test
1. A nurse is explaining the procedure for inserting an indwelling urinary catheter. Which of the
following explanations regarding anchoring the catheter would be most accurate?
a) An indwelling catheter tube is secured to a female patient’s abdomen to prevent
accidental dislodgment.
b) An indwelling catheter tube is secured to the male’s inner thigh with a strip of
nonallergenic tape or a commercial tube holder.
c) It is important to anchor the catheter tubing in order to minimize the risk for urethral
trauma, minimize bladder spasms from traction, and prevent accidental dislodgment.
d) When securing the catheter tubing, slack in the catheter should be avoided to prevent
movement and possible tissue injury.
Correct answer: c
Rationale: Securing the catheter will minimize the accidental dislodgment of the catheter. It also
minimizes the risk for bleeding, trauma, meatal necrosis, and bladder spasms from pressure and
traction. Male patient catheter tubes are attached to the lower abdomen or to top of the thigh;
female patient tubes are attached to the inner thigh. Allow slack in catheter so that movement
does not create tension on the catheter.
2. The nursing assistive personnel (NAP) reports leakage around a patient’s urinary catheter.
What action should the nurse take first?
a) Attempt to reinflate the balloon.
b) Increase the patient’s fluid intake, and reassess in 1 hour.
c) Remove the catheter and replace with a smaller size.
d) Obtain a urine specimen.
Correct answer: a
Rationale: Leakage around the urinary catheter could indicate that the catheter inserted was too
small or that the balloon failed. The nurse should attempt to reinflate the balloon and, if this does
not work, then replace the catheter. Increasing the patient’s fluid intake would not improve a
leaking catheter. If the patient had a low hourly urine output, this may be appropriate. If the
cause is not a faulty balloon, the nurse may need to contact the physician in order to get an order
for a larger catheter. The patient is not exhibiting symptoms of infection, so there is no need for
an order for any laboratory testing of a urine sample.
3. The nurse has been called to make a home visit to a patient with a history of a spinal cord
injury and an indwelling Foley catheter. The patient appears diaphoretic and his face is flushed.
The nurse takes the patient’s vital signs with the following results: Temperature 98.4° F, pulse
54, respirations 20, and blood pressure 160/100. The patient’s head of the bed is elevated. What
action should the nurse take next?
a) Notify the physician.
b) Check for any kinks in catheter tubing.
c) Have the patient take slow deep breaths.
d) Lower the head of the bed.
Correct answer: b
Rationale: Autonomic dysreflexia is a medical emergency caused by bladder (or bowel)
distention after spinal cord injury. The first action should be to assess for bladder fullness and
drain the patient’s bladder (i.e., empty bladder by removing any blockage and/or kinks in the
catheter tubing). The patient’s head should be elevated. If this does not resolve the patient’s
symptoms, the nurse may consult with the physician.
4. The nursing assistive personnel (NAP) is helping the nurse insert a Foley catheter on a male
patient. In which position should the NAP place the patient?
a) Sim’s position
b) Dorsal recumbent
c) Supine with legs adducted
d) Supine with legs slightly abducted
Correct answer: d
Rationale: Sim’s position would be appropriate for a female patient with mobility limitations or
for a male who cannot lie flat. The dorsal recumbent position would be appropriate for
catheterizing a fe
[Show More]
