MEDICAL COLLEGES OF NORTHERN PHILIPPINES

Alimannao Hills, Peablanca Cagayan

COLLEGE OF NURSING

GENERAL INSTRUCTIONS: 1. This test questionnaire contains 100 questions. 2. This exam is for 2 hours only. You must pass your answer sheet when the time allotted has elapsed. Answer sheets that will be passed after the allotted time will NOT BE ACCEPTED. 3. Shade only (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your answer. 4. Do not put any unnecessary markings on the answer sheet. Doing so will invalidate your answers. 5. Keep the answer sheets neat and clean. DO NOT MUTILATE.

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1. Anna is about to insert a foley catheter to a male patient who have a case of Benign Prostatic Hypertrophy. She knows that therapeutic indications include all but one. a. Urinary retention b. Instillation of medication c. Bladder drainage d. Collection of urine specimen 2. Diagnostic indication includes all but one. a. Obtain urine sample b. Measure postvoid residual volume c. Monitor urine output d. Removal of blood clots 3. While assessing the patient, Nurse Anna noted a urethral injury of the patient. Which of the following should the nurse do? a. Notify the physician b. Do not insert catheter c. Push through with the procedure as long as with antibiotic therapy d. All except B 4. A nurse who has just inserted a foley catheter noticed the urine in bag of water color red. Which of the following should the nurse do FIRST? a. Assess the patient and placement of foley catheter b. Remove the catheter c. Inform the physician d. All of the above 5. Which of the following could be sign/signs of injury of a patient who has indwelling catheter? a. Blood at the urethral meatus b. Gross hematuria c. All of the above d. None of the above 6. Equipment should properly prepared before starting the procedure. Which of the following should not be included in the preparation? a. Sterile gloves b. Antiseptic swab c. Clamps d. Sterile gauze 7. During preparation, Nurse Anna should bear in mind that a 10-cc syringe should be prefilled with water prior to insertion.

a. True c. Partially True b. False d. Partially False 8. ChaCha is a 7-year old patient who has urinary retention. Doctor ordered insertion of foley catheter. The nurse should anticipate to prepare what size of the catheter? a. Fr. 14 or less than b. Fr. 14-16 c. Fr. 18 d. Fr. 20-24 9. An applicable size of the catheter should be appropriate with the age. For adult female, it is recommended to use which of the following? a. Fr. 14 b. Fr. 14-16 c. Fr. 18 d. Fr.18-24 10. One of the complications of urinary catheter which very common is which of the following? a. Trauma b. Infection c. Hypogastric pain d. Stricture 11. Patients who have the tendency to have difficulty of catheter insertion are the following except? a. Previous childbirth b. Obesity c. Anal injury d. None of the above 12. After 10 minutes of catheterization, the nurse noted no urine backflow. Which of the following could be a reason? a. Obstructed catheter b. Empty bladder c. Wrong placement d. All of the above 13. It is the passing of plastic tube through the patientss urethra into the bladder to permit the passage of urine. a. Continuous bladder irrigation b. Catheterization c. Balloon inflation d. All of the above 14. It is important to assess the client first before catheterization to ensure that problem will not arise. It is also essential for the nurse to recognize circumstances when assistance is required. Which of the following is/are included? a. Patients who are confused b. Patient who are anxious c. Patient who bare diabetic d. All of the above 15. When performing catheter insertion, nurse should always take note of the importance of which of the following? a. Aseptic technique b. Clean technique c. Both A & B d. None of the above 16. The length of the ureters of a male patient is:

a. Equal to the length of the ureters of a female patient b. Longer than the length of the ureters of a female patient c. Shorter than the length of the ureters of a female patient d. None of the above 17. In inserting a catheter into a child patient, the nurse must use what catheter size? a. 8-10 Fr b. 14-16 Fr c. 18 Fr d. 19-20 Fr 18. To inflate the urinary catheter balloon, the nurse must preferably use which of the following? a. NSS b. Saline c. Sterile Water d. Oxygen 19. While the nurse is inserting a Foley Catheter to a female patient, she accidentally slips the catheter into the vagina. What should the nurse do next? a. Use the same catheter in inserting in the urinary meatus b. Discard, use new sterile catheter c. Use a new clean catheter d. Wash the catheter with NSS and insert it to the urinary meatus 20. What position should the nurse instruct a male patient to assume when inserting a catheter? a. Dorsal recumbent: feet at about 2 feet apart b. Left lateral: feet 1 feet apart c. Prone position: Legs separated by a pillow d. Supine: thighs slightly abducted 21. A type of catheter that is inserted to drain the bladder and then removed immediately. a. Coude b. Retention c. Straight d. None of the above 22. Which of the following purposes of condom catheterization if mentioned by the student nurse need further instruction? a. To relieve bladder distention b. To irrigate the bladder c. To instill medication into the scrotum d. To measure residual urine Residual Urine 23. Which of the following daily nursing action would be inappropriate to include for a client with a Foley catheter in the early postoperative period after major surgery? a. Position the catheter to drain freely b. Encourage adequate amounts of fluids unless contraindicated by pre-existing problems c. Ambulate the client d. Measure I&O 24. A nurse knows that when doing aseptic technique, proper hand washing should be done how many minutes? a. 5 minutes b. 5-10 minutes c. 10 minutes d. 10-15minutes

25. When performing insertion of catheter, the nurse knows that friction should be avoided to prevent trauma. Application of which of the following should be implemented? a. Sterile water b. Lubricant c. Antiseptic solution d. All of the above 26. All of the following is done to alleviate the anxiety of the patient except for one. a. Explain the procedure to the patient b. Providing drape during the procedure c. Restraining patient if aggressive d. Provide privacy 27. Hospital-aquired urinary tract infections (UTIs) are often related to poor hand washing and: a. Poor urinary output b. Poor perineal hygiene c. Use of urinary drainage bags d. Improper catheter care 28. The nurse recognizes that the organism that most frequently causes urinary tract infections (UTIs) in women is: A. Aspergillus B. Streptococcus C. Escherichia coli D. Staphylococcus aureus 29. The nurse is about to insert a urinary catheter into an uncircumcise patient. After retracting the foreskin and inserting and securing the catheter, the nurse must be sure to: a. Secure the catheter to the client's leg. b. Clean the urinary meatus with povidone-iodine c. Return the foreskin over the glans penis. d. Culture the first urine to drain into the collecting bag. 30. When inserting a foley catheter to a female patient the nurse should follow proper way of cleaning the meatus using which technique? a. Circular motion b. Back to front starting from the labia majora to labia minora to meatus c. Back to front starting from meatus to labia minora to labia majora d. Any of the above 31. Balloon should be tested prior to insertion to ensure that catheter will be anchore in the bladder. a. True c. partially True b. False d. partially false 32. When catheter has been inserted, it is necessary to check if is secured by doing which of the following? a. Request for x-ray to check placement b. Gently pull the catheter until balloon is snug against bladder wall c. Gently assess the placement by palpating the bladder d. All except a 33. Set the bed to a comfortable height to work and raise the side rail opposite you. This step in inserting catheter is for which of the following reason/s? a. For nurses comfort b. For patients safety c. Both A&B d. None of the above 34. During insertion Nurse Kasandra felt a resistance. What should her priority during this time?

a. Pull out the catheter and delay insertion b. Ask the patient to do deep-breathing c. Discontinue and relay to the physician d. All except C 35. A nurse is caring for a patient who is one day postpartum. While assessing she noticed that the uterus is palpated not in the midline but on the right lower hypogastric area. Possible reason could the which of the following? a. Bladder distention b. Urinary retention c. Both A&B d. None of the above 36. A student was asked by a patient why urinary tract infection is always common to female patients. The student should base his answer from the following. a. Female are always prone to UTI due to elimination habit b. Female meatus is covered by the labia majora & minor unlike male meatus which are exposed c. The urethra of the female is shorter than the male d. All of the above 37. A practice guideline for nurses to use in preventing catheter- associated infection includes which of the following? a. Maintain clean technique when inserting catheter in the patient b. Disconnect the catheter and drainage tubing once a shift to rinse the unit in cleanibg the device c. Since you are wearing gloves, it is not necessary to wash hands d. Prevent contamination of the catheter with feces in the incontinent patient 38. You are monitoring a postpartum patients urine output. You noted that the urine output for 2 hours is 60mL. Which of the following should you appropriately do? a. Check for obstruction b. Note this as normal c. Inform the physician since it is decreased d. Change the catheter following the aseptic technique 39. A patient has gross hematuria. The appropriate size of the catheter to be inserted should be which of the following? a. Fr.14 b. Fr. 16 c. Fr. 8-10 d. Fr. 24 40. When preparing equipment, the nurse should know that the lubricant she should include is: a. Water-based b. Oil-based c. Either of the two d. None of the above II. Write True if the statement is correct and False if the statement is incorrect. 1. When client is aggressive during catheterization, restraints must be implemented 2. It is important to percuss the bladder to check for fullness or distention prior to catheterization 3. Oil-based lubricant should always be used to aid in decreasing friction

4. Downward stroke starting at the labia majora should be performed during catheter insertion to prevent contamination of feces 5. Extra catheter should also be included in the prepared equipment during catheterization 6. Indwelling catheter should include a collection bag and tubing 7. Male patients could assume the flat on bed position with knees adducted 8. When inserting catheter to male patients, xylocaine of 5-10mL could be injected 9. If inflation of balloon causes discomfort or pain to the patient, withdraw catheter and discontinue procedure 10. Male are more at risk to develop UTI than female III. Arrange the following by numbering each item sequentially. (FEMALE CATHETERIZATION) Position the patient in dorsal recumbent and provide adequate lighting Identify client and check physicians order Lubricate the catheter. Use the nondominant hand to spread the labia and establish firm and gentle position Pick up cleansing cotton ball using forceps in your dominant hand and wipe in a downward stroke starting in the labia minora and one stroke in the center over the meatus Assess the patient and explain the procedure Advance the catheter 2 inches further until urine floe through it Handwash, don sterile gloves and provide privacy Prepare all materials needed Insert catheter by grasping the catheter 2-3 inches from the tip and ask client to deep breathe Remove gloves and wash hands Wipe the perineal are for remaining antiseptic or lubricant Inflate the balloon with a 10cc sterile water Discard all used materials Attach the end o f the catheter to the collection bag Documentation Anchor/ Secure the tubing or indwelling catheter to the inner thigh of the patient
God Bless!

Prepared by: IRISH BANATAO- BASAN, RN, MAN Level II Clinical Instructor

Noted by: JACQUELINE DE-ASIS- ALAMO, RN, MSN Level I&II Coordinator

Recommending approval: REYNALDO M. ADDUCUL, RN, RM, MSN Dean, College of Nursing

Approved by

PRESENITA C. AGUON, Ph.D Vice- President for Academic Affairs