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NURS 275 SKILLS CHECK OFF TEST 2 & 3 COMBINED STUDY GUIDE WITH COMPLETE SOLUTION!!
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NURS 275 SKILLS CHECK OFF TEST 2 & 3 COMBINED STUDY GUIDE WITH COMPLETE SOLUTION!!
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NURS 275 SKILLS CHECK OFF TEST 2 & 3 COMBINEDSTUDY GUIDE WITH COMPLETE SOLUTION!!
Urinary Catheter Insertion & Removal: FEMALE
Standards of Practice:
Testing the catheter balloon no longer recommended (may distort, stretch, &
damage balloon)
answers: Emerging evidence suggests the use of a local anesthetic (Lidocaine gel)
compared to plain lubrication gel
(aqueous) significantly decreases patient pain & discomfort during catheter
insertion. Ten to 15 mLs of the gel is
instilled directly into the urethra; allow 3 to 5 minutes for effect before
catheterization
Post-removal observations: measure & document first voiding amount & time
answers: Standard Documentation insertion: date, time, signature; procedure,
catheter type, size, & balloon volume;
urine amount & character; patient tolerance
Standard Documentation removal: date, time, signature; procedure, balloon fluid
volume removed; patient
tolerance
answers: Verifies physician's order for purpose/outcome of urinary intubation:
indwelling, straight catheter, specimen collection, relieve distention, residual
Performs standard greeting & prep
answers: Checks for allergies: povidone-iodine, Betadine, adhesives/tape, latex,
lubricant
, Gathers equipment: urinary catheter kit with 14-16 Fr., 5-10 mL balloon Foley
answers: Raises bed to comfortable height, faces patient from left side of bed, if
right-handed
Clears and disinfects bedside table: wipes twice with chlorhexidine, or sodium
hypochlorite; places kit on table
answers: Positions patient in supine position with knees flexed & thighs externally
rotated
Performs hand hygiene & applies clean gloves
answers: Drapes patient with sheet/blanket, exposing pubis to thighs
Washes perineal area with soap & water; dries skin areas thoroughly; removes &
discards gloves
answers: Performs hand hygiene
On bedside table, opens urinary catheterization kit; maintaining sterility using no-
touch technique
answers: Performs hand hygiene and applies sterile gloves
Applies sterile drape, using no-touch technique: drape cuff over both hands, slips
cuffed edge just under buttocks
answers: Applies sterile gloves; maintaining aseptic technique, unfolds fenestrated
drape, applies to expose only labia
Arranges contents of kit for easy reach (on bed between patient's legs); opens
antiseptic & saturates cotton balls (or opens swab sticks); positions drainage bag
(pre-connected to catheter) between patient's legs at knee level
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