A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?

Skin breakdown

Infection

Neurogenic bladder

Phlebitis

Answer and Explanation

The Correct Answer is B

A)   Skin breakdown could occur due to the catheter bag lying in bed, but it is not the primary risk associated with the observations noted.
B)   A kinked IV tubing can lead to stasis of fluids, which increases the risk of infection. Additionally, if the urinary catheter bag is not positioned below the level of the bladder, urine can reflux back into the bladder, which also increases the risk of infection.
C)   Neurogenic bladder is a condition typically associated with nerve damage, not directly related to the position of the catheter bag or kinked tubing.
D)   Phlebitis is inflammation of a vein, which would not be directly caused by the issues noted with the urinary catheter.

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Correct Answer is B

Explanation

A. Changing dressings is important but not the priority over assessing cardiac status in an electrical shock injury.
B. Obtaining an ECG is the priority to assess for any cardiac dysrhythmias, which can be immediate and life-threatening consequences of electrical shock injuries.
C. Administering pain medication can be done once the client's cardiac status has been evaluated and stabilized.
D. While maintaining adequate urine output is important, assessing cardiac status takes precedence.

A. Wear an N95 respirator when providing direct client care. B. Make sure the client's room has positive-pressure airflow. C. Make sure dietary plates and utensils are disposable. D. Monitor the client's temperature once every 6 hr.

Correct Answer is B

Explanation

A) While wearing an N95 respirator may be necessary for certain infections, it is not a routine precaution for clients in protective isolation.
B) Ensuring the client's room has positive-pressure airflow helps prevent the entry of airborne pathogens into the room, reducing the risk of infection for the immunocompromised client.
C) Using disposable plates and utensils helps reduce the risk of cross-contamination and infection transmission but is not directly related to airborne infection control.
D) Monitoring the client's temperature is important for assessing for signs of infection, but it does not directly prevent infection transmission in the same way as positive-pressure airflow.

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A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?

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