A nurse in an urgent care clinic is caring for a client who reports recently using methylenedioxy-methamphetamine.
Which of the following findings should the nurse expect?

The correct answer is: B. Secure the tubing with adhesive tape to the lower abdomen.

Choice A rationale: Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine reflux, which can lead to urinary tract infections (UTIs).

Choice B rationale: Securing the tubing with adhesive tape to the lower abdomen is correct as it helps to prevent accidental pulling or tugging on the catheter, maintaining its position and reducing the risk of dislodgement.

Choice C rationale: Collecting a sterile specimen from the urinary drainage bag is incorrect. Specimens should be collected from the sampling port, not directly from the drainage bag, to ensure sterility.

Choice D rationale: Coiling the tubing on the bed above the collection bag is incorrect as it can cause urine to flow back into the bladder, increasing the risk of infection.

Choice A rationale:

Elevating the head of the client's bed for 1 hour after the feeding is the correct choice because it helps reduce the risk of aspiration. Elevating the head of the bed at a 30-45 degree angle can promote the flow of enteral feeding solution into the jejunum, reducing the risk of reflux into the stomach and subsequent aspiration.

Choice B rationale:

Administering the feeding solution at a cold temperature is not recommended. Enteral feedings should be given at or near room temperature to prevent discomfort and cramping in the client.

Choice C rationale:

Rotating the jejunostomy tube once per day is not a standard practice. The tube should be secured in place to prevent dislodgement, but routine rotation is not necessary.

Choice D rationale:

Flushing the tube with 90 mL of sterile water before and after the feeding is not necessary for intermittent bolus enteral feedings. Flushing before and after continuous feedings may be required to maintain patency, but for intermittent bolus feedings, it is not a routine practice.