Author Question: After the insertion of a catheter into the stoma of a continent diversion, a nurse observes that ... (Read 32 times)

schs14 · **on:** Jul 24, 2018

After the insertion of a catheter into the stoma of a continent diversion, a nurse observes that there is no return. The nurse should first:

A. Irrigate the catheter
B. Discontinue the procedure
C. Try moving the catheter in and out slightly
D. Remove the catheter and flush out clots or debris

Question 2

The nurse is helping the patient prepare for surgery. The patient has removed her jewelry and glasses. Which action should the nurse take to keep the jewelry safe?

a. Put these items in the patient's bedside stand.
b. Inventory the items and give them to the family.
c. Place the items in a plastic bag and send them to the OR with the patient.
d. Keep these items with her until the patient returns.

akpaschal · **Reply #1 on:** Jul 24, 2018

Answer to Question 1

C
C. If no effluent starts to drain, problem solving is needed. The illustration in the text can be used to help solve the problem of inadequate effluent from pouch. For example, try moving catheter in and out slightly.
A. Moving catheter in and out slightly, have client move side to side, or cough. If these actions do not cause drainage, then gently irrigate the catheter with 30 to 60 ml of sterile saline.
B. Before withdrawing catheter, have client cough three or four times, then slowly remove.
D. Positive pressure inside abdomen clears residual urine or stool from pouch and continence valve; clears mucus from catheter.

Answer to Question 2

B
Inventory the items and give them to family members, or have security lock them up. Document a list of items and their locations in a preoperative checklist and/or in the nurses' notes per agency policy. Valuables left in the patient's room may be lost or stolen. Items not secured could be misplaced or lost. Keeping the items with the nurse creates a liability for the nurse.