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    Exam Review

    1. The patient reports feeling an urge to urinate even though an indwelling urinary catheter is in place. Which is the priority action of the nurse?
      A)
      Measure the patient's urinary output.
      B)
      Ensure that the catheter tubing is not kinked.
      C)
      Provide perineal care to the patient for comfort.
      D)
      Reassure the patient that the sensation is to be expected.
    2. The nurse is discontinuing the patient's indwelling urinary catheter. The catheter is not easily withdrawn after the balloon is deflated. Which is the appropriate nursing action?
      A)
      Reattach the syringe and attempt to withdraw more water from the balloon.
      B)
      Ask the patient to bear down as the catheter is withdrawn with gentle pressure.
      C)
      Review the patient's chart to see how much water was inserted into the balloon.
      D)
      Explain to the patient that removal of the catheter may cause significant discomfort.
    3. The home care nurse is caring for a patient with an indwelling urinary catheter after spinal cord The catheter is patent with clear yellow urine after being in place for 8 weeks. Which is the ap action of the nurse?
      A)
      Request an order for a urinalysis with culture and sensitivity.
      B)
      Irrigate the patient's catheter using 60 mL of sterile normal saline.
      C)
      Remove the catheter immediately and notify the health care provider.
      D)
      Contact the health care provider for an order to change the catheter.
    4. A patient with a Foley catheter inserted 3 days ago needs a urine sample for culture and sensitivity. What is the appropriate action for the nurse to take?
      A)
      Disconnect the drainage tube from the catheter.
      B)
      Withdraw urine from the closed system drainage bag.
      C)
      Empty contents of the drainage bag into the specimen cup.
      D)
      Attach a sterile syringe to the catheter port to withdraw urine.
    Page 1 of 10

    Exam Review

    1. The patient has a catheter that must be irrigated. The nurse is using a needleless closed irrigation technique. In which order will the nurse perform the steps, starting with the first one?
      A)
      Clean injection port.
      3
      B)
      Inject prescribed solution.
      5
      C)
      Twist needleless syringe into port.
      4
      D)
      Remove clamp and allow to drain.
      6
      E)
      Clamp catheter just below specimen port.
      2
      F)
      Draw up prescribed amount of sterile solution ordered.
      1
    2. What allergies should the nurse assess for before inserting a catheter in a patient? (Select all that apply)
      (SATA)
      A)
      Betadine
      B)
      Shellfish
      C)
      Latex
      D)
      Silicone
      E)
      Tape
    3. Which nursing actions will the nurse implement when collecting a urine specimen from a patient? (Select all that apply.)
      (SATA)
      A)
      Growing urine cultures for up to 12 hours
      B)
      Labeling all specimens with date, time, and initials
      C)
      Allowing the patient adequate time and privacy to void
      D)
      Wearing gown, gloves, and mask for all specimen handling
      E)
      Transporting specimens to the laboratory in a timely manner
      F)
      Collecting the specimen from the drainage bag of an indwelling catheter
    4. Which findings should the nurse follow up on after removal of a catheter from a patient? (Select all that apply)
      (SATA)
      A)
      Increasing fluid intake
      B)
      Dribbling of urine
      C)
      Voiding in small amounts
      D)
      Voiding within 6 hours of catheter removal
      E)
      Burning with the first couple of times voiding
    Page 2 of 10

    Exam Review

    1. Put the following steps for catheter insertion in order.
      A)
      Gather supplies
      2
      B)
      Obtain urine specimen
      4
      C)
      Review the physician order
      1
      D)
      Secure the bag to leg
      5
      E)
      Perform pericare
      3
    2. The nurse understands the best way to reduce catheter-associated urinary tract infections (CAUTIs) in long term indwelling catheters is to do what?
      A)
      Perform catheter care twice a day
      B)
      Replace the catheter on a routine basis
      C)
      Administer cranberry tablets three times a day
      D)
      Administer prophylactic antibiotics twice a day for the duration of the catheter
    3. How much urine is too much to drain at one time when a new insertion of a foley catheter is done?
      A)
      300-450 ml
      B)
      450-600 ml
      C)
      750-1000 ml
      D)
      200-500 ml
    4. Where do you collect the urine specimen from on a patient with an indwelling catheter on day two?
      A)
      Port on catheter
      B)
      Drainage valve on bag
      C)
      Tip of catheter
      D)
      Balloon port
    Page 3 of 10

    Exam Review

    1. A confused patient with pneumonia is admitted with an indwelling catheter in place. During interdisciplinary rounds the following day, which question would the nurse ask the primary healthcare provider?
      A)
      "Do you want daily weights on this patient?"
      B)
      "Will the patient be able to return home?"
      C)
      "Can we discontinue the indwelling catheter?"
      D)
      "Should we get another chest x-ray today?"
    2. A nurse is caring for a patient who has a prescription for a 24-hour urine collection. Which of the following actions should the nurse take?
      A)
      Discard the first voiding.
      B)
      Keep the urine in a single container at room temperature.
      C)
      Dispose of the last voiding.
      D)
      Ask the client to urinate into the toilet, stopping midstream, and finish urinating into the specimen
    3. No urine in the urethra. What should the nurse do?
      A)
      Throw the catheter way and begin again.
      B)
      Fill the balloon with the recommended sterile water.
      C)
      Remove the catheter, wipe with alcohol, and reinsert after lubrication.
      D)
      Leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter.
    4. The patient has a catheter that must be irrigated. The nurse is using a needleless closed irrigation technique. In which order will the nurse perform the steps, starting with the first one?
      A)
      Clean injection port.
      B)
      Inject prescribed solution.
      C)
      Twist needleless syringe into port.
      D)
      Remove clamp and allow to drain.
      E)
      Clamp catheter just below specimen port.
      F)
      Draw up prescribed amount of sterile solution ordered.
    Page 4 of 10

    Exam Review

    1. A nurse is inserting an indwelling urinary catheter for a male patient. Which action will the nurse take??
      A)
      Hold the shaft of the penis at a 60-degree angle.
      B)
      Hold the shaft of the penis with the dominant hand.
      C)
      Cleanse the meatus 3 times with the same cotton ball from clean to dirty.
      D)
      Cleanse the meatus with circular strokes beginning at the meatus and working outward
    2. The nurse will anticipate inserting a Coudé catheter for which patient?
      A)
      An 8-year-old male undergoing anesthesia for a tonsillectomy
      B)
      A 24-year-old female who is going into labor
      C)
      A 56-year-old male admitted for bladder irrigation
      D)
      An 86-year-old female admitted for a urinary tract infection
    3. A nurse is evaluating a nursing assistive personnel's (AP) care for a patient with an indwelling catheter. Which action by the AP will cause the nurse to intervene?
      A)
      Emptying the drainage bag when half full
      B)
      Kinking the catheter tubing to obtain a urine specimen
      C)
      Placing the drainage bag on the side rail of the patient's bed
      D)
      Securing the catheter tubing to the patient's thigh
    4. A nurse is caring for a male patient experiencing urinary retention. Which action should the nurse take first?
      A)
      Limit fluid intake.
      B)
      Insert a urinary catheter.
      C)
      Assist to a standing position.
      D)
      Ask for a diuretic medication.
    Page 5 of 10

    Exam Review

    1. Nurses need to implement appropriate body mechanics in order to prevent injury to themselves and their clients. Which principle of body mechanics should the nurse incorporate into client care?
      A)
      Flex the knees and keep the feet apart.
      B)
      Assume a position far enough away from the client.
      C)
      Twist the body in the direction of movement.
      D)
      Use the strong back muscles for lifting or moving.
    2. An average-size male client has right-sided hemiparesis. The nurse helps this client to walk by:
      A)
      Standing at his left side and holding his arm
      B)
      Standing at his left side and holding one arm around his waist
      C)
      Standing at his right side and holding his arm
      D)
      Standing at his right side and holding one arm around his waist
    3. A nurse is preparing to culture a client's wound to determine if it is infected. Which of these steps should the nurse take?
      A)
      Irrigate the wound with antiseptic, swab over granulation tissue, and replace swab in culture tube.
      B)
      Irrigate the wound with saline, swab over granulation tissue, and replace swab in culture tube.
      C)
      Irrigate the wound with antiseptic, swab over eschar, and replace swab in culture tube.
      D)
      Swab over granulation tissue, replace swab in culture tube, and redress the wound.
    4. The nurse is trying to decide which of the following to delegate to the certified nursing assistant. Which of the following could be safely delegated?
      A)
      An assessment of a client experiencing chest pain
      B)
      An admission assessment on a newly admitted patient
      C)
      Vital signs on a client that is ready for discharge
      D)
      Administration of oral medications
    Page 6 of 10