A nurse is assisting with the care of a client.

The nurse is collecting data from the client.

Select words from the choices below to fill in each blank in the following sentence.

The nurse should identify that

_______

and

__________

indicate manifestations of borderline personality disorder.

A. Review the need for the indwelling urinary catheter daily: Daily review of catheter necessity reduces the risk of catheter-associated urinary tract infections (CAUTIs). Prompt removal when no longer needed limits bacterial entry and colonization, which significantly lowers infection rates in hospitalized clients.

B. Empty the drainage bag when it is half full: The drainage bag should be emptied when it is about two-thirds full, not half full, to prevent backflow and reduce strain on the system. Emptying too early or too often increases the risk of introducing pathogens into the closed system.

C. Use soap and water to provide perineal care: Using soap and water for perineal hygiene maintains cleanliness and reduces bacterial colonization near the catheter site. Routine perineal care is a critical intervention to minimize the risk of ascending infections into the urinary tract.

D. Place the drainage bag on the bed when transporting the client: The drainage bag must remain below bladder level during transport to prevent backflow of urine into the bladder. Placing the bag on the bed risks contamination and promotes reflux of potentially infected urine.

E. Encourage the client to drink 1000 mL of fluid daily: Although hydration generally helps prevent UTIs, this client is on a strict 1000 mL fluid restriction due to heart failure. Encouraging more fluid intake could worsen fluid overload and does not align with current prescribed therapy.

F. Change the indwelling urinary catheter tubing every 3 days: Routine changing of catheter tubing is not recommended unless clinically indicated (e.g., contamination, obstruction, infection). Unnecessary manipulation increases the risk of introducing pathogens into the urinary system.

A. A nursing colleague documenting vitals in the electronic medical record (EMR) of a client that the colleague is caring for: This is appropriate documentation practice. Nurses are responsible for documenting client information in the EMR when they provide direct care, ensuring accurate and timely records.

B. A nursing colleague printing material that does not contain identifiable information from a client's electronic medical record (EMR) for professional use: If no identifiable client information is included, and it is for professional, educational, or training purposes, this action is acceptable and does not violate confidentiality.

C. A nursing colleague discussing a client's diagnosis with another staff member on the unit who is not involved in the client's care: Discussing confidential client information with staff not directly involved in the client's care is a violation of HIPAA and breaches client privacy. Only staff responsible for the client's care should access or discuss their health information.

D. A nursing colleague discussing a client's treatment plan with another nurse on the unit as part of the end-of-shift handoff report: This is appropriate because handoff reports ensure continuity of care. Discussing necessary client information with the next caregiver is essential for safe, effective client management.