Podcast
Questions and Answers
The nurse has delegated to nursing assistive personnel (NAP) the skill of assisting with a bedpan for a patient who has had discomfort when walking to the bathroom. Which statement made by the NAP requires the nurse’s follow-up?
The nurse has delegated to nursing assistive personnel (NAP) the skill of assisting with a bedpan for a patient who has had discomfort when walking to the bathroom. Which statement made by the NAP requires the nurse’s follow-up?
A patient with a nasogastric tube, an intravenous infusion line, and an indwelling urinary catheter needs to be placed on the bedpan. Which action would the nurse take first to ensure the patient’s safety?
A patient with a nasogastric tube, an intravenous infusion line, and an indwelling urinary catheter needs to be placed on the bedpan. Which action would the nurse take first to ensure the patient’s safety?
A dependent, confused patient is being given a bedpan. How can the nurse best ensure the patient’s safety?
A dependent, confused patient is being given a bedpan. How can the nurse best ensure the patient’s safety?
The nurse is assisting with a bedpan for a patient who had knee surgery 24 hours ago. What is the best way for the nurse to maximize comfort while the patient uses the bedpan?
The nurse is assisting with a bedpan for a patient who had knee surgery 24 hours ago. What is the best way for the nurse to maximize comfort while the patient uses the bedpan?
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After assisting with a bedpan, the nurse notes that the patient’s stool is streaked with bright-red blood. What would the nurse do first?
After assisting with a bedpan, the nurse notes that the patient’s stool is streaked with bright-red blood. What would the nurse do first?
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A patient with male genitalia on bed rest is permitted to stand to use the urinal. Which action would the nurse take to ensure his safety before helping the patient to a standing position?
A patient with male genitalia on bed rest is permitted to stand to use the urinal. Which action would the nurse take to ensure his safety before helping the patient to a standing position?
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The nurse is delegating to nursing assistive personnel (NAP) the task of assisting with a urinal. The nurse specifies to NAP that the urinal is to be used in bed, not in a standing position, for which patient?
The nurse is delegating to nursing assistive personnel (NAP) the task of assisting with a urinal. The nurse specifies to NAP that the urinal is to be used in bed, not in a standing position, for which patient?
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Why would the nurse assess a patient’s abdomen before helping with the use of a urinal?
Why would the nurse assess a patient’s abdomen before helping with the use of a urinal?
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The nurse is assisting a patient with the placement of a urinal. The patient tells the nurse, “I’ll call you when I’m done.” What is the nurse’s best response?
The nurse is assisting a patient with the placement of a urinal. The patient tells the nurse, “I’ll call you when I’m done.” What is the nurse’s best response?
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Which action promotes infection control when assisting a patient with a urinal?
Which action promotes infection control when assisting a patient with a urinal?
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Which action would the nurse take to reduce the risk for a catheter-associated urinary tract infection (CAUTI) in a patient with an indwelling urinary catheter?
Which action would the nurse take to reduce the risk for a catheter-associated urinary tract infection (CAUTI) in a patient with an indwelling urinary catheter?
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Which action(s) would minimize the patient’s risk for injury during insertion of an indwelling urinary catheter?
Which action(s) would minimize the patient’s risk for injury during insertion of an indwelling urinary catheter?
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Which statement best illustrates the nurse’s understanding of the role of nursing assistive personnel (NAP) when inserting an indwelling urinary catheter in a female patient?
Which statement best illustrates the nurse’s understanding of the role of nursing assistive personnel (NAP) when inserting an indwelling urinary catheter in a female patient?
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The nurse has completed the initial inspection of the patient’s perineum and is preparing to insert an indwelling urinary catheter. Which action would the nurse complete next?
The nurse has completed the initial inspection of the patient’s perineum and is preparing to insert an indwelling urinary catheter. Which action would the nurse complete next?
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A female patient placed in the dorsal recumbent position for the insertion of an indwelling urinary catheter tells the nurse that she “doesn’t feel comfortable in this position” and that her “back really hurts.” What is the nurse’s best response?
A female patient placed in the dorsal recumbent position for the insertion of an indwelling urinary catheter tells the nurse that she “doesn’t feel comfortable in this position” and that her “back really hurts.” What is the nurse’s best response?
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What is the best reason for the nurse to instruct a male patient to take slow, deep breaths during insertion of an indwelling urinary catheter?
What is the best reason for the nurse to instruct a male patient to take slow, deep breaths during insertion of an indwelling urinary catheter?
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When preparing to insert an indwelling urinary catheter in a male patient, it is important for the nurse to do what?
When preparing to insert an indwelling urinary catheter in a male patient, it is important for the nurse to do what?
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Which observation indicates that instruction given to nursing assistive personnel (NAP) in caring for a patient with an indwelling urinary catheter has been effective?
Which observation indicates that instruction given to nursing assistive personnel (NAP) in caring for a patient with an indwelling urinary catheter has been effective?
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Which action will the nurse implement to reduce the risk of catheter-associated urinary tract infection (CAUTI) in a male patient with an indwelling urinary catheter?
Which action will the nurse implement to reduce the risk of catheter-associated urinary tract infection (CAUTI) in a male patient with an indwelling urinary catheter?
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While setting up the sterile field in preparation for inserting an indwelling urinary catheter, a male patient is incontinent of urine over most of the supplies. What action would the nurse take to reduce the patient’s risk for infection?
While setting up the sterile field in preparation for inserting an indwelling urinary catheter, a male patient is incontinent of urine over most of the supplies. What action would the nurse take to reduce the patient’s risk for infection?
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When preparing to discharge a patient who had an indwelling urinary catheter removed 24 hours ago, the nurse would offer patient education regarding which common complication?
When preparing to discharge a patient who had an indwelling urinary catheter removed 24 hours ago, the nurse would offer patient education regarding which common complication?
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Which action would best minimize a patient’s risk for infection during removal of an indwelling urinary catheter?
Which action would best minimize a patient’s risk for infection during removal of an indwelling urinary catheter?
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Which statement might the nurse make to nursing assistive personnel (NAP) caring for a patient who has just had an indwelling urinary catheter removed?
Which statement might the nurse make to nursing assistive personnel (NAP) caring for a patient who has just had an indwelling urinary catheter removed?
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Which nursing action minimizes a patient’s risk for injury during removal of an indwelling urinary catheter?
Which nursing action minimizes a patient’s risk for injury during removal of an indwelling urinary catheter?
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Which is not an expected outcome on a first voiding after catheter removal?
Which is not an expected outcome on a first voiding after catheter removal?
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The nurse is delegating to nursing assistive personnel (NAP) the perineal care of a female patient who is totally dependent and confined to bed. Which statement by the NAP requires the nurse's follow-up?
The nurse is delegating to nursing assistive personnel (NAP) the perineal care of a female patient who is totally dependent and confined to bed. Which statement by the NAP requires the nurse's follow-up?
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The nurse is preparing to provide perineal care for a female patient who is on bed rest. Which patient position should the nurse use for this care?
The nurse is preparing to provide perineal care for a female patient who is on bed rest. Which patient position should the nurse use for this care?
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As the nurse is preparing to provide perineal care to a female patient with limited mobility, the patient says, "I can do that myself." Which action would be the priority?
As the nurse is preparing to provide perineal care to a female patient with limited mobility, the patient says, "I can do that myself." Which action would be the priority?
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How can the nurse promote infection control while providing perineal care for a female patient who has a catheter?
How can the nurse promote infection control while providing perineal care for a female patient who has a catheter?
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The nurse is delegating a female patient's perineal care to nursing assistive personnel (NAP). Which instruction would the nurse give to ensure the NAP's safety while performing this care?
The nurse is delegating a female patient's perineal care to nursing assistive personnel (NAP). Which instruction would the nurse give to ensure the NAP's safety while performing this care?
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Which of the following interventions directly related to patient safety must the nurse consider when providing perineal care to an elderly male patient with a catheter?
Which of the following interventions directly related to patient safety must the nurse consider when providing perineal care to an elderly male patient with a catheter?
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The nurse observes the nursing assistive personnel (NAP) providing perineal care to a male patient. Which observation of care requires the nurse's follow-up?
The nurse observes the nursing assistive personnel (NAP) providing perineal care to a male patient. Which observation of care requires the nurse's follow-up?
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A male patient receiving perineal care tells the nurse "It has started to hurt a little down there." What is the nurse's best response?
A male patient receiving perineal care tells the nurse "It has started to hurt a little down there." What is the nurse's best response?
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The nurse has delegated a male patient's perineal care to the nursing assistive personnel (NAP). Which statement made by the NAP requires the nurse's follow-up?
The nurse has delegated a male patient's perineal care to the nursing assistive personnel (NAP). Which statement made by the NAP requires the nurse's follow-up?
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What is the primary reason for performing perineal care on a male patient with incontinence?
What is the primary reason for performing perineal care on a male patient with incontinence?
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What is the purpose of a condom catheter?
What is the purpose of a condom catheter?
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What is the correct method for applying a condom catheter?
What is the correct method for applying a condom catheter?
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How often should a condom catheter be changed?
How often should a condom catheter be changed?
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A person has a condom catheter that must be secured with elastic tape. How should you apply the tape?
A person has a condom catheter that must be secured with elastic tape. How should you apply the tape?
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After connecting the condom catheter to the drainage tubing, what should you do with the excess tubing?
After connecting the condom catheter to the drainage tubing, what should you do with the excess tubing?
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After bacteria are cultured from a midstream urine specimen, what is accomplished by sensitivity testing?
After bacteria are cultured from a midstream urine specimen, what is accomplished by sensitivity testing?
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What can the nurse do to help ensure an accurate result when collecting a midstream urine sample for a patient who is menstruating?
What can the nurse do to help ensure an accurate result when collecting a midstream urine sample for a patient who is menstruating?
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Which statement might the nurse make to nursing assistive personnel (NAP) assigned to collect a midstream urine specimen from a patient with signs of a urinary tract infection?
Which statement might the nurse make to nursing assistive personnel (NAP) assigned to collect a midstream urine specimen from a patient with signs of a urinary tract infection?
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Which statement might the nurse make to nursing assistive personnel (NAP) in order to help ensure reliable results of culture and sensitivity testing of a midstream urine specimen?
Which statement might the nurse make to nursing assistive personnel (NAP) in order to help ensure reliable results of culture and sensitivity testing of a midstream urine specimen?
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What is the most important action the nurse can take to ensure that a midstream urine specimen does not become contaminated?
What is the most important action the nurse can take to ensure that a midstream urine specimen does not become contaminated?
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During intermittent open bladder irrigation, a patient complains of pain. Which action would the nurse take first?
During intermittent open bladder irrigation, a patient complains of pain. Which action would the nurse take first?
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Which action would the nurse take to minimize a patient’s risk for injury during urinary catheter irrigation?
Which action would the nurse take to minimize a patient’s risk for injury during urinary catheter irrigation?
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Which instruction might the nurse give to nursing assistive personnel (NAP) helping to care for a patient receiving bladder irrigation?
Which instruction might the nurse give to nursing assistive personnel (NAP) helping to care for a patient receiving bladder irrigation?
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Which action is most important in reducing the risk for infection in a patient receiving open intermittent irrigation of a urinary catheter?
Which action is most important in reducing the risk for infection in a patient receiving open intermittent irrigation of a urinary catheter?
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Which action would the nurse take to manage continuous urinary catheter irrigation for a patient whose urine is bright red and contains clots?
Which action would the nurse take to manage continuous urinary catheter irrigation for a patient whose urine is bright red and contains clots?
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Why does the nurse need to keep the urine sterile while obtaining a sample from an indwelling urinary catheter?
Why does the nurse need to keep the urine sterile while obtaining a sample from an indwelling urinary catheter?
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Which action will ensure that a sterile urine specimen is handled properly in order to help obtain reliable results?
Which action will ensure that a sterile urine specimen is handled properly in order to help obtain reliable results?
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Which statement might the nurse make to nursing assistive personnel (NAP) before delegating the collection of a routine urine sample from a patient with an indwelling urinary catheter?
Which statement might the nurse make to nursing assistive personnel (NAP) before delegating the collection of a routine urine sample from a patient with an indwelling urinary catheter?
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Which measure may be taken to minimize the staff’s risk for infection from a urine specimen?
Which measure may be taken to minimize the staff’s risk for infection from a urine specimen?
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When collecting a urine specimen from an indwelling urinary catheter, which action is most likely to ensure that sufficient urine is collected?
When collecting a urine specimen from an indwelling urinary catheter, which action is most likely to ensure that sufficient urine is collected?
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While performing an intermittent straight urinary catheterization of a female patient, the nurse inadvertently inserts the catheter into the patient’s vagina. Which action would the nurse take next?
While performing an intermittent straight urinary catheterization of a female patient, the nurse inadvertently inserts the catheter into the patient’s vagina. Which action would the nurse take next?
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While attempting to perform a straight catheterization for a male patient, the nurse advances the catheter 3 to 4 inches into the meatus but observes no urine flow. Which action would the nurse take at this time?
While attempting to perform a straight catheterization for a male patient, the nurse advances the catheter 3 to 4 inches into the meatus but observes no urine flow. Which action would the nurse take at this time?
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The nurse instructs nursing assistive personnel (NAP) regarding proper technique for intermittent straight catheterization of a male patient. Which statement made by NAP indicates that the instruction was effective?
The nurse instructs nursing assistive personnel (NAP) regarding proper technique for intermittent straight catheterization of a male patient. Which statement made by NAP indicates that the instruction was effective?
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Why does the nurse cleanse a female patient’s perineum before inserting an intermittent urinary catheter?
Why does the nurse cleanse a female patient’s perineum before inserting an intermittent urinary catheter?
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The nurse has completed an intermittent straight urinary catheterization of a female patient. Which action would the nurse delegate to nursing assistive personnel (NAP)?
The nurse has completed an intermittent straight urinary catheterization of a female patient. Which action would the nurse delegate to nursing assistive personnel (NAP)?
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Which action would the nurse take to ensure the safety of an older adult patient who has received an enema?
Which action would the nurse take to ensure the safety of an older adult patient who has received an enema?
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The nurse is preparing to administer an enema. How can the nurse best facilitate insertion of the rectal tube?
The nurse is preparing to administer an enema. How can the nurse best facilitate insertion of the rectal tube?
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The nurse is delegating to nursing assistive personnel (NAP) the administration of an enema for an older adult patient who is recovering from a stroke. The enema order reads, “Enemas until clear.” Which statement made by NAP requires the nurse to follow-up?
The nurse is delegating to nursing assistive personnel (NAP) the administration of an enema for an older adult patient who is recovering from a stroke. The enema order reads, “Enemas until clear.” Which statement made by NAP requires the nurse to follow-up?
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The nurse has delegated administration of a standard enema for a 72-year-old patient with constipation. Which statement made by nursing assistive personnel (NAP) requires the nurse to follow-up?
The nurse has delegated administration of a standard enema for a 72-year-old patient with constipation. Which statement made by nursing assistive personnel (NAP) requires the nurse to follow-up?
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Which action would the nurse take to reduce the risk of infection among patients and staff when administering an enema to an older adult patient with dementia?
Which action would the nurse take to reduce the risk of infection among patients and staff when administering an enema to an older adult patient with dementia?
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What is the correct order for abdominal assessment?
What is the correct order for abdominal assessment?
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How often should normal bowel sounds be heard in each quadrant of the abdomen?
How often should normal bowel sounds be heard in each quadrant of the abdomen?
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Which of the following is an important part of performing an abdominal assessment?
Which of the following is an important part of performing an abdominal assessment?
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What should you do if a patient is ticklish when you are palpating the abdomen?
What should you do if a patient is ticklish when you are palpating the abdomen?
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Moderate and deep palpation of the abdomen:
Moderate and deep palpation of the abdomen:
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What is the initial step in preparing a fecal occult blood test?
What is the initial step in preparing a fecal occult blood test?
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The nurse has delegated to nursing assistive personnel (NAP) the task of performing fecal occult blood tests on the stool of a patient with a history of positive results. Which instruction is most relevant to performing this test in this particular patient?
The nurse has delegated to nursing assistive personnel (NAP) the task of performing fecal occult blood tests on the stool of a patient with a history of positive results. Which instruction is most relevant to performing this test in this particular patient?
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Which instruction to nursing assistive personnel (NAP) is most relevant to the proper performance of a fecal occult blood test using a Hemoccult slide?
Which instruction to nursing assistive personnel (NAP) is most relevant to the proper performance of a fecal occult blood test using a Hemoccult slide?
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Which statement indicates proper interpretation of the results of a positive fecal occult blood test?
Which statement indicates proper interpretation of the results of a positive fecal occult blood test?
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Which of the following nursing actions addresses the risk for infection related to fecal occult blood testing?
Which of the following nursing actions addresses the risk for infection related to fecal occult blood testing?
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Which action will the nurse perform first when preparing to change a patient’s urostomy pouching system?
Which action will the nurse perform first when preparing to change a patient’s urostomy pouching system?
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When pouching a patient’s urostomy, which nursing action reduces the risk for injury?
When pouching a patient’s urostomy, which nursing action reduces the risk for injury?
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What will the nurse do to protect the peristomal skin of a patient with a urostomy?
What will the nurse do to protect the peristomal skin of a patient with a urostomy?
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Which action would be the nurse’s priority when caring for a patient with a urostomy who had no urine output for 4 hours?
Which action would be the nurse’s priority when caring for a patient with a urostomy who had no urine output for 4 hours?
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Which instruction might the nurse give to nursing assistive personnel (NAP) caring for a patient with a newly established urostomy?
Which instruction might the nurse give to nursing assistive personnel (NAP) caring for a patient with a newly established urostomy?
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A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient’s pain?
A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient’s pain?
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Which action reduces the nurse’s risk for infection when changing the dressing of an infected abdominal wound?
Which action reduces the nurse’s risk for infection when changing the dressing of an infected abdominal wound?
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What is the nurse’s best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago?
What is the nurse’s best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago?
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When changing a patient’s surgical dressing 24 hours postoperatively, when would the nurse apply sterile gloves?
When changing a patient’s surgical dressing 24 hours postoperatively, when would the nurse apply sterile gloves?
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Which action would minimize the risk for cross-contamination while cleansing an infected abdominal surgical wound?
Which action would minimize the risk for cross-contamination while cleansing an infected abdominal surgical wound?
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When irrigating a wound, how would the nurse know the right amount of pressure to apply?
When irrigating a wound, how would the nurse know the right amount of pressure to apply?
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Which action should the nurse avoid before irrigating a patient’s foot wound?
Which action should the nurse avoid before irrigating a patient’s foot wound?
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Which device is used for wound irrigation?
Which device is used for wound irrigation?
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Which imaging study or diagnostic test would the nurse review to determine if the pressure injury on a patient’s left heel is infected?
Which imaging study or diagnostic test would the nurse review to determine if the pressure injury on a patient’s left heel is infected?
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A nurse is irrigating a patient’s abdominal wound 2 days postoperatively. Which finding would need to be reported to the health care provider?
A nurse is irrigating a patient’s abdominal wound 2 days postoperatively. Which finding would need to be reported to the health care provider?
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Which practice protects the nurse from infection when changing the dressing on an infected pressure injury?
Which practice protects the nurse from infection when changing the dressing on an infected pressure injury?
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The wound bed of a patient’s pressure injury is red. What does this finding indicate to the nurse?
The wound bed of a patient’s pressure injury is red. What does this finding indicate to the nurse?
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Which measurements would the nurse use to calculate the surface area of a patient’s pressure injury?
Which measurements would the nurse use to calculate the surface area of a patient’s pressure injury?
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How would the nurse safely apply an enzyme debridement ointment?
How would the nurse safely apply an enzyme debridement ointment?
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Which action can the nurse delegate to nursing assistive personnel (NAP) to help prevent the development of pressure injury in an older adult patient?
Which action can the nurse delegate to nursing assistive personnel (NAP) to help prevent the development of pressure injury in an older adult patient?
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A patient who had surgery yesterday has the initial dressing covering the surgical site. What is the nurse’s responsibility in assessing this patient’s wound?
A patient who had surgery yesterday has the initial dressing covering the surgical site. What is the nurse’s responsibility in assessing this patient’s wound?
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Which wound would be allowed to heal by secondary intention?
Which wound would be allowed to heal by secondary intention?
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Before performing a wound assessment, which nursing action would reduce the patient’s risk for infection?
Before performing a wound assessment, which nursing action would reduce the patient’s risk for infection?
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Which intervention can the nurse delegate to nursing assistive personnel (NAP) in caring for a patient with a wound?
Which intervention can the nurse delegate to nursing assistive personnel (NAP) in caring for a patient with a wound?
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The nurse notes that a patient’s surgical wound is healing slowly. Which health problem would contribute to slow wound healing?
The nurse notes that a patient’s surgical wound is healing slowly. Which health problem would contribute to slow wound healing?
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What is the proper method for cleansing the evacuation port of a wound drainage system?
What is the proper method for cleansing the evacuation port of a wound drainage system?
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What is the nursing action to set up suction for a Hemovac drainage system?
What is the nursing action to set up suction for a Hemovac drainage system?
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When emptying a Jackson-Pratt drain, which issue should nursing assistive personnel (NAP) report immediately to the nurse as a potential abnormality?
When emptying a Jackson-Pratt drain, which issue should nursing assistive personnel (NAP) report immediately to the nurse as a potential abnormality?
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Which action might the nurse perform to ensure that the wound drainage tubing does not pull on the insertion site?
Which action might the nurse perform to ensure that the wound drainage tubing does not pull on the insertion site?
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Which action would maximize the suction produced by the Jackson-Pratt drainage system after the system has been emptied?
Which action would maximize the suction produced by the Jackson-Pratt drainage system after the system has been emptied?
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The health care provider writes an order for a culture specimen to be collected from a patient with a dog bite wound. What would the nurse do first?
The health care provider writes an order for a culture specimen to be collected from a patient with a dog bite wound. What would the nurse do first?
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Which action would the nurse take to reduce the risk for wound infection when collecting a specimen for culture?
Which action would the nurse take to reduce the risk for wound infection when collecting a specimen for culture?
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Which question might the nurse ask the patient when an aerobic wound culture has been ordered?
Which question might the nurse ask the patient when an aerobic wound culture has been ordered?
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Which instruction might the nurse give to the NAP to help ensure that a wound culture specimen will be transported properly?
Which instruction might the nurse give to the NAP to help ensure that a wound culture specimen will be transported properly?
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Which nursing action demonstrates proper procedure in the collection of a wound culture specimen?
Which nursing action demonstrates proper procedure in the collection of a wound culture specimen?
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Study Notes
Delegating Bedpan Assistance
- The nurse should follow-up with the NAP if the NAP states that a patient with a nasogastric tube, IV infusion line, and an indwelling urinary catheter needs a bedpan.
- The nurse should first ensure the safety of a dependent, confused patient before assisting with a bedpan.
- The nurse should maximize comfort while the patient uses the bedpan by ensuring proper positioning and providing privacy.
- The nurse should notify the healthcare provider if a patient’s stool is streaked with bright-red blood.
Ensuring Patient Safety
- Before assisting a patient on bed rest to a standing position, the nurse should assess the patient’s ability to stand safely and provide support.
- The nurse should delegate a urinal to be used in bed, not in a standing position, for patients who are unstable, confused, or have a medical condition that limits standing.
Urinary Catheterization
- The nurse should assess a patient’s abdomen before assisting them with the use of a urinal to identify any discomfort or distention.
- The nurse should ensure proper positioning, adequate lighting, and hand hygiene when assisting a patient with the placement of a urinal.
- To reduce the risk of CAUTI, the nurse should encourage fluid intake, maintain closed drainage, and avoid unnecessary catheter manipulation.
- The nurse should minimize the patient’s risk for injury during catheter insertion by using proper sterile technique, lubricating the catheter tip, and reassuring the patient.
- The nurse should ensure the NAP understands the role of maintaining sterile technique and assisting with positioning during the catheterization process.
- The nurse should cleanse the urinary meatus with an antiseptic solution before inserting the catheter.
- If the patient reports discomfort, the nurse should consider repositioning, use proper lubrication, and provide reassurance.
- The nurse should instruct the patient to take slow, deep breaths during the insertion of a catheter to promote relaxation and reduce discomfort.
- The nurse should ensure the catheter is inserted into the urethra and not the vagina during female catheterization.
- The nurse should monitor for urine flow 2 to 3 inches into the meatus during male catheterization to ensure proper catheter placement.
- The nurse should assess the patient’s urine output and color following insertion of the catheter.
- The nurse should implement measures to reduce the risk of CAUTI in a male patient with an indwelling urinary catheter, such as maintaining a closed urinary drainage system, encouraging fluid intake, and avoiding unnecessary catheter manipulation.
- The nurse should re-establish the sterile field and change the patient’s supplies if the sterile field becomes contaminated with urine during catheterization.
Managing a Urinary Catheter
- The nurse should educate the patient regarding potential complications after indwelling urinary catheter removal, such as urinary retention.
- To minimize the risk of infection, the nurse should use proper sterile technique when removing the catheter.
- The nurse should instruct the NAP to monitor the patient’s urinary output after catheter removal.
- The nurse should instruct the NAP to check for patency of the urethra and ensure the catheter is intact before removing the catheter.
- The nurse should ensure that the patient voids within 6 hours of catheter removal.
Providing Perineal Care
- The nurse should follow-up with the NAP if they state that they are not comfortable providing perineal care to a patient.
- The nurse should position the patient in a side-lying position, with their hips and knees flexed, when providing perineal care.
- The nurse should always respect the patient’s autonomy and allow them to participate in their care as much as possible.
- To promote infection control while providing perineal care, the nurse should wear gloves and use a clean technique.
- The nurse should keep the surrounding environment safe for the NAP by ensuring adequate lighting, a clean work surface, and appropriate supplies.
- The nurse should provide perineal care to an older adult male patient with a catheter using gentle washing techniques and avoid applying excessive pressure to prevent skin injury.
- When providing perineal care for a patient with a catheter, the nurse should use separate washcloths for each area of the body and avoid contamination of the catheter site.
- The nurse should encourage an older adult male patient to report any pain or discomfort during perineal care.
- The nurse should follow-up with the NAP if they are unable to provide perineal care to a patient safely and effectively.
Urinary Tract Infection (UTI)
- The nurse should perform perineal care to reduce the risk of UTI.
- The nurse should ensure a condom catheter is correctly applied to minimize the risk of UTI.
- The nurse should change a condom catheter every 24 hours to minimize the risk of UTI.
- The nurse should ensure the tape is secure to prevent skin breakdown, ensure proper fit, and prevent urine leakage to minimize the risk of UTI.
- The nurse should secure the excess tubing to the patient’s leg to prevent accidental drainage and contamination.
- The nurse should ensure a midstream urine specimen is correctly obtained to reduce the risk of contaminating the sample and ensure the correct organism is identified.
- After culturing the midstream urine specimen, sensitivity testing identifies which antibiotics will be effective against the bacteria.
- The nurse should ensure that a midstream urine specimen is collected from a menstruating woman at a time when she is not actively bleeding to reduce the risk of contamination.
- The nurse can instruct the NAP to collect a urine specimen for culture and sensitivity testing by explaining the importance of hand hygiene, using a sterile container, and avoiding contamination of the urine.
- The nurse can instruct the NAP to collect a midstream urine specimen from a patient with signs of UTI by explaining the importance of collecting the specimen from the middle of the urinary stream.
- The most important action the nurse can take to ensure a midstream urine specimen does not become contaminated is to ensure proper hand hygiene and use sterile equipment.
Bladder Irrigation
- The nurse should stop the irrigation and notify the healthcare provider if a patient experiences pain during intermittent open bladder irrigation.
- The nurse should avoid using excessive force or pressure when irrigating a bladder to minimize the risk of injury.
- The nurse should instruct the NAP to monitor the amount of irrigation solution instilled and the amount of fluid returned to ensure the process is successful.
- The nurse should ensure all equipment and supplies are sterile and provide proper instruction to the NAP to reduce the risk of infection.
- The nurse should use continuous bladder irrigation for a patient whose urine is bright red and contains clots to maintain patent urinary catheterization.
Urinary Catheter Sample Collection
- The nurse should ensure a sterile urine specimen is collected from an indwelling urinary catheter to avoid contamination.
- The nurse should ensure proper insertion and locking of the catheter clamp to prevent contamination of the specimen.
- The nurse should monitor the patient’s urine output, specifically for any changes in color or consistency.
- The nurse should instruct the NAP to follow standard precautions when collecting a urine specimen from a patient with an indwelling urinary catheter to minimize the risk of infection.
Intermittent Straight Urinary Catheterization
- The nurse should remove the catheter and notify the healthcare provider if the catheter inadvertently enters the vagina during female catheterization.
- If the nurse encounters resistance or no urine flow while inserting a catheter into a male urethra, they should stop, assess the situation, and seek assistance.
- The nurse should ensure that the NAP understands the importance of using proper sterile techniques and providing patient comfort during intermittent straight catheterization.
- The nurse should cleanse the female perineum with antiseptic solution before inserting an intermittent urinary catheter to prevent infection.
- The nurse can delegate the disposal of the catheter to the NAP after the procedure.
- The nurse should advise the NAP to monitor the patient for any changes in urinary output or discomfort after the procedure.
Enema Administration
- To ensure the safety of an older adult patient who has received an enema, the nurse should monitor for signs of complications such as abdominal cramping or hypotension.
- The nurse should lubricate the rectal tube and gently insert it into the rectum to facilitate insertion.
- If the NAP states they are unable to administer the enema until clear, the nurse should follow up as this is not a standard practice.
- The nurse should follow up with the NAP if they administer an enema to a patient with constipation without assessing the patient’s bowel sounds or recent bowel movements.
- The nurse should implement standard infection control precautions to reduce the risk of infection when administering an enema.
Bowel Assessment
- The nurse should follow the order of inspection, auscultation, percussion, and palpation when assessing a patient’s abdomen.
- Normal bowel sounds should be heard at least every 5 to 15 seconds in each quadrant of the abdomen.
- The nurse should assess appearance, contour, and symmetry during an abdominal assessment.
- To prevent ticklishness during abdominal palpation, the nurse should engage the patient in conversation and ensure their comfort.
- If the patient is ticklish, the nurse should gently approach the palpation area and warm their hands before starting.
- Moderate palpation should gently depress the abdomen 1 to 2 cm, while deep palpation should gently depress the abdomen 4 to 5 cm.
Fecal Occult Blood Test
- The nurse should use a clean and dry container to collect a fecal occult blood test specimen and obtain a sample from the patient’s stool.
- If a patient has a history of positive fecal occult blood tests, the nurse should instruct the NAP to follow up with a healthcare provider for further diagnostic testing.
- The nurse should instruct the NAP to ensure that the specimen is evenly spread on the slide for a fecal occult blood test and use a new slide for each specimen.
- A positive fecal occult blood test indicates the presence of blood in the stool, and a follow-up with the healthcare provider is needed.
- The nurse should use proper hand hygiene and clean equipment to minimize the risk of infection during fecal occult blood testing.
- The nurse should maintain proper infection control to reduce the risk of infection related to fecal occult blood testing.
Ostomy Care
- To protect the peristomal skin of a patient with a urostomy, the nurse should apply a skin barrier paste before applying the pouching system.
- The nurse should irrigate the stoma with warm water to clear mucus and debris.
- The nurse should assess stoma size, color, and output to ensure proper functioning of the urostomy.
- The nurse should observe for signs and symptoms of stomal ischemia to determine if a medical emergency intervention is needed.
Wound Care
- The nurse should assess the wound for signs of infection and notify the healthcare provider if there are any signs of a wound infection.
- The nurse should use alcohol to cleanse the wound area to reduce the risk of infection.
- If the additional bloody drainage from the initial surgical dressing is excessive or persistent, the nurse should notify the healthcare provider.
- The nurse should apply sterile gloves when changing the dressing 24 hours postoperatively to ensure a sterile environment.
- The nurse should carefully irrigate the wound with mild pressure to avoid injury and prevent contamination.
- The nurse should ensure that the patient doesn’t feel any pain while irrigating their wound.
- The nurse should use a sterile syringe with a catheter tip to irrigate the wound to prevent contamination and ensure the correct method.
- The nurse should review the patient’s recent imaging and diagnostic test results, including any laboratory reports, to determine if a pressure injury is infected.
- The nurse should notify the healthcare provider if they notice any significant change to the patient’s wound.
- The nurse should wear appropriate personal protective equipment (PPE), including gloves, gowns, and masks, to protect themselves from infection.
- The nurse should assess the size, depth, and exudate of the wound and communicate any updates to the healthcare provider.
- The nurse should use a ruler to measure the length, width, and depth of the wound to calculate the surface area and assess healing progress.
- The nurse can teach a patient how to protect their skin as a preventative measure to avoid developing pressure injuries.
- The nurse should examine the surgical wound to ensure that it is healing correctly.
- Wounds that are allowed to heal by secondary intention are wounds that are left open to heal with the formation of granulation tissue.
- The nurse should use proper hand hygiene to prevent the patient from developing an infection.
- The nurse can delegate the task of providing wound care to the NAP.
- Slow wound healing can be a sign of a health problem such as diabetes, malnutrition, or poor circulation.
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Description
This quiz examines the appropriate delegation of nursing tasks to nursing assistive personnel (NAP), particularly in the context of assisting patients with bedpan usage. Pay attention to the statements made by NAP and identify those that necessitate further follow-up by the nurse.
