Author Question: A nurse is caring for a hospitalized patient with a urinary catheter. Which nursing action best ... (Read 32 times)

strangeaffliction · **on:** Jul 22, 2018

A nurse is caring for a hospitalized patient with a urinary catheter. Which nursing action best prevents the patient from acquiring an infection?

a. Maintaining a closed urinary drainage system
b. Inserting the catheter using strict clean technique
c. Disconnecting and replacing the catheter drainage bag once per shift
d. Fully inflating the catheter's balloon according to the manufacturer's recommendation

Question 2

The nurse is preparing to apply an external catheter. Which action will the nurse take?

a. Allow 1 to 2 inches of space between the tip of the penis and the end of the catheter.
b. Spiral wrap the penile shaft using adhesive tape to secure the catheter.
c. Twist the catheter before applying drainage tubing to the end of the catheter.
d. Shave the pubic area before applying the catheter.

fdliggud · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: A
A key intervention to prevent infection is maintaining a closed urinary drainage system. A catheter should be inserted in the hospital setting using sterile technique. Inflating the balloon fully prevents dislodgment and trauma, not infection. Disconnecting the drainage bag from the catheter creates a break in the system and an open portal of entry and increases risk of infection.

Answer to Question 2

ANS: A
When applying an external catheter, allow 2.5 to 5 cm (1 to 2 inches) of space between the tip of the penis and the end of the catheter. Spiral wrap the penile shaft with supplied elastic adhesive. The strip should not overlap. The elastic strip should be snug but not tight. NOTE: Never use adhesive tape. Connect drainage tubing to the end of the condom catheter. Be sure the condom is not twisted. Connect the catheter to a large-volume drainage bag or leg. Clip hair at the base of the penile shaft, as necessary. Do not shave the pubic area.