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39 Cards in this Set

  • Front
  • Back
The purpose of urinary catheterization?
assist w. normal elimination
eliminate urinary retention
certain surgical procedures
Straight urinary catheterization ?
inserted to drain the bladder and then immediately removed.
single lumen
small eye (opening) 1/2 inch from tip
Retention catheterization


Foley catheterization
double lumen. small lumen= used to inflate balloon to keep cath. in place.
large lumen=drains urine.
usually connected to a closed gravity drainage system.
closed system
Closed retention systems
cannot be opened anywhere along the system, from the catheter to collection bag.
What should the nurse instruct the client to do before she advances the catheter?
take a slow deep breath and then advance catheter as the client exhales.
After urine begins to flow, how far should the nurse advance the catheter?
another 2 inches, to be sure the catheter is within the bladder.
What technique should the nurse apply when removing a catheter? Sterile or clean?
clean technique
Key points for the removal of a retention catheter?
remove any tape used to keep catheter in place.
deflate balloon.
after all fluid is removed from the balloon, remove catheter=place in trash.
dry perineal area remove gloves
measure urine
compare intake and output
During straight catherization of a female client, if the catheter slips into the vagina, the nurse should?
leave the catheter in place and get a new sterile catheter.
Sterile technique is required when inserting a catheter to prevent?
ascending urinary infections
What care is needed to the perineal area after there is a catheter inserted?
no special meatus or perineal care is required. Routine perineal care is all that is needed.
What should be done if the nurse observes sediment in the catheter or tubing or impaired urinary drainage?
the nurse should remove the catheter and the drainage system and replaced with a closed catheter and drainage system
What is a potential problem once a retention catheter is removed?
may require bladder retraining to regain bladder muscle control( can be prevented by clamping catheter for periods of time before actual removal)
swelling of the urethra may inhibit voiding (should be assessed until voiding is reestablished.
What is the purpose of bladder irrigation?
maintain patency of urinary catheter and tubing= continuous irrigation
free a blockage in a urinary catheter or tubing=intermittent irrigation
What is the purpose of a clean catch urine or midstream urine specimen?
to determine the presence of microorganisms.
the type of organisms
the antibiotics the organisms are sensitive to
clean voided urine is obtained for ?
routine urinalysis
A client is to obtain a clean-catch urine specimen. Which statement by the client demonstrates a lack of understanding regarding the procedure?
"Urinate into the cup as soon as I start to go."
A certified nursing assistant is collecting a 24-hour urine specimen from a client. Which statement by the assistant indicates that the specimen collection will need to be restarted?
"I used a container from the lab that has a preservative in it."
"The client voided in it right away, and I wrote the time on the container."
"I have the container in a plastic bucket with ice in it."
"I told the client that every single urination must be put in the container. If one is missed, call one of us."
"The client voided in it right away, and I wrote the time on the container."
client is to obtain a clean-catch urine specimen. Which statement by the client demonstrates a lack of understanding regarding the procedure?
"I should use all of the towelettes in the kit and use each only once."
"Urinate into the cup as soon as I start to go."
"I don't have to fill the cup. Just get an ounce or two."
"Put the cover on right away, without touching the inside of the cover or the cup."
urinate into the cup as soon as I start to go.
How are 24 hour urine specimen stored until completed?
refrigerated or contain a preservative to avoid bacterial growth or decomposition of urine components
What is the purpose of a timed urine collection?
assess the kidney's ability to concentrate and dilute urine.
determine disorders of glucose metabolism EX: diabetes mellitus.
levels of specific constituents in the urine.
To obtain a timed urine specimen.
obtain container and preservative
label container
provide a clean receptacle to obtain urine.
post signs in room, kardex, bathroom
save all urine.
at the start of period have client void and then discard this sample.
avoid contamination w. toilet paper or feces
at end of period have client completely empty bladder and save urine
record collection of the specimen, time started, time stopped
What happens if the client or staff forgets and discards the clients urine ?
the procedure must be restarted from the beginning.
reason for an indwelling catheter specimen
to collect a sterile urine specimen
to collect a specimen from a Foley (retention)catheter.
clean gloves
if no urine:clamp catheter for 30min.
wipe area where needle will be inserted
insert needle at a 30-45 angle (helps self sealing of rubber)
unclamp catheter
withdraw required amount of urine
transfer the urine to container
discard syringe
cap container
remove gloves and discard
label container
record collection
note the procedure
Aspiration of a urine specimen from an indwelling catheter can only be done if the catheter contains a ?
self sealing rubber catheters.
Hydrocolloid is an example of what type of dressing?
an absorbent
What should the nurse avoid when applying a transparent dressing?
avoid stretching the dressing: which restricts movement.
THe nurse knows she must use a ________
technique when applying a hydocolloid dressing.
What is the purpose of a hydrocolliod dressing?
maintain moist environment
prevent entry of microorganisms
minimize discomfort
promote breakdown of necrotic material by white blood cells.
decrease frequency of dressing changes
Removing a dressing requires what type of gloves?
cleaning a wound and applying a new dressing requires what type of gloves?
After applying a transparent dressing the nurse documents?
dressing change
wound status
clients response
What is the best dressing for a pressure ulcer with a shallow, partial skin thickness, eroded areas but no necrotic areas.
Signs of urinary infection?
abdomial pain
cloudy urine
older clients=confusion
Why should a client with a catheter be given large amounts of fluids?
to encourage urine flow and minimize infetion, and the risk of sediment blocking the drainage tubing
Condom catheter care
leave a 1 inch space between the condom and the end of the penis.
secure the condom snugly: not tightly
inspect the penis 30 minutes after insertion.
change the condom every 24 hours.
Catheter length
catheter gauge
for a male client
40cm lenght
#18 gauge
catheter length
catheter gauge
for a female client
22 cm
#14 or #16 gauge