Nursing Procedures and Interventions

Quiz 15 Notes

Catheter Removal

• To prevent injury when removing an indwelling catheter, ensure you deflate the catheter balloon completely.

Post-Foley Catheter Assessment

• After removing a Foley catheter, carefully assess the client for signs of a urinary tract infection (UTI).

Enema Administration: Solution Height

• Holding the enema solution container too high results in fast running solution, causing distention and cramping. The height should be correct.

Indwelling Catheter Insertion: Aseptic Technique

• When inserting an indwelling catheter, the primary reason to use sterile technique is to avoid introducing microorganisms.

Male Catheterization Positioning

• To position a male client for urinary catheterization, place him in a supine position with thighs slightly abducted.

Foley Catheter Purpose

• A Foley catheter is used in an elderly and immobile client with urinary incontinence to maintain skin integrity.

Cleansing Enema Administration

• When administering a cleansing enema, position the container $30$ cm (or $12$ inches) above the anus.

Nasogastric Tube Placement Check

• After inserting a nasogastric tube, check for proper placement by:
  • Listening for a gurgling or swishing sound with a stethoscope over the stomach while injecting air into the tube.
  • Attempting to aspirate gastric contents with a syringe.

Non-Invasive Urine Collection

• A condom catheter is considered a non-invasive method of collecting urine from an incontinent patient.

Fecal Impaction Removal Positioning

• The Sims position is recommended for a patient undergoing fecal impaction removal.

Female Catheterization Troubleshooting

• If, when catheterizing a female client, the nurse inserts the catheter $4$ to $5$ inches and no urine is detected, the most likely reason is that the catheter is in the vagina.

Indwelling Catheter Balloon Integrity Test

• To test the integrity of the balloon of an indwelling catheter, inject and aspirate normal saline or sterile water.

Urinary Incontinence Intervention

• For a client who complains of losing small amounts of urine when sneezing or laughing, suggest Kegel exercises.

Soapsuds Enema Administration

• If a client receiving a $500$ mL soapsuds enema states they feel like they need to go to the bathroom after administering $200$ mL of solution, clamp the tubing for a short time.

Enema Tubing Air Purging

• To purge air from enema tubing when administering a water and soap solution enema, open the clamp and fill the tube with solution.

Routine Catheter Care

• Routine catheter care involves cleaning the first $2$ inches of the catheter with soap and water every shift.

Catheterization for Paraplegic Client

• A left-hand dominant nurse preparing to perform catheterization for a paraplegic client should stand on the client's right side.

Female Catheter Lubrication

• When inserting an indwelling catheter for an adult female client, lubricate the catheter $3 \frac{1}{2}$ to $5$ cm.

Urine Output Assessment with Foley Catheter

• To best assess urine characteristics in a client with an indwelling Foley catheter, assess urine in the drainage tubing.

Enema Procedure Order

• Correct order for performing an enema:
  1. Confirm the client's identity by checking their arm band.
  2. Provide privacy by closing the curtains.
  3. Assist the client into Sims position.
  4. Insert the tip of the enema tubing into the client's rectum.

Stoma Care Instructions

• Instruct patients to diligently clean fecal matter from around the stoma because it can cause irritation and skin breakdown.

Catheterization Privacy

• When preparing to perform a catheterization to obtain a specimen and the client voices concerns about privacy, close the door and cover the client during the procedure.

Tap Water Enema Discomfort

• During tap water enema administration, to relieve cramping, lower the height of the solution container.

Male Catheterization Discomfort

• When inserting a urinary catheter into a male client and inflating the balloon causes discomfort, withdraw fluid from the balloon and advance the catheter forward.

Female Perineum Cleaning

• When cleaning the female perineum before catheterization, cleanse with strokes from front to back.

Fecal Impaction Risk Factors

• Clients on bed rest and with poor fiber intake are at higher risk for fecal impaction.

Indwelling Catheter Insertion in Males

• When inserting an indwelling catheter in a male client, inflate the balloon after seeing urine in the tubing, then advance $1$ to $1 \frac{1}{2}$ inches more.

Vaginal Catheterization

• If the nurse suspects the urinary catheter has been accidentally placed in the client's vagina, leave the catheter in place and insert another sterile catheter into the meatus.

Catheter Care Instructions

• Instructions for catheter care: Clean from the urinary meatus down the catheter.

Bladder Training

• Bladder training instructions for a patient with a history of urinary incontinence: Void every $1 \frac{1}{2}$ to $2$ hours while awake.

Urethral Catheter Size Range

• The size range for urethral catheters is $14$ to $24$ French.

Nasogastric Tube Insertion Distance

• To determine the correct distance to insert a nasogastric tube, measure from the tip of the nose to the ear lobe to the xiphoid process.