A nurse is assisting with the care of a client who had an indwelling urinary catheter inserted 3 days ago. Which of the following actions should the nurse take?
Change the catheter bag every 3 days and as needed.
Obtain urine from the drainage bag if a urinary specimen is required.
Use a catheter securing device to hold the catheter in place.
Position the drainage bag higher than the client's bladder.
The Correct Answer is C
A. Change the catheter bag every 3 days and as needed.: Bags are typically changed only if they are leaking, obstructed, or according to specific facility policy; frequent opening of the system increases infection risk.
B. Obtain urine from the drainage bag if a urinary specimen is required.: Urine in the bag is stagnant and colonized with bacteria. Specimens must be taken from the sampling port using a sterile syringe.
C. Use a catheter securing device to hold the catheter in place.: Securing the catheter to the leg prevents traction and trauma to the urethral meatus, reducing the risk of inflammation and infection.
D. Position the drainage bag higher than the client's bladder.: The bag must remain below the level of the bladder to prevent the backflow of urine, which causes UTIs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
A. History of hyperlipidemia: High lipids do not directly impair the physiological process of wound healing.
B. History of diabetes mellitus: Diabetes impairs healing due to decreased vascular perfusion and the fact that high glucose levels inhibit white blood cell function.
C. Prealbumin level: The client’s level (13 mg/dL) is below the normal range (15–36 mg/dL). Prealbumin is the best indicator of acute nutritional status; low levels indicate a protein deficiency necessary for tissue repair.
D. Cholesterol level: While slightly elevated (210 mg/dL), this is a risk for cardiovascular disease, not a primary factor in delayed wound healing.
E. Mini Nutritional Assessment (MNA) score: A score of 7 (out of 14) indicates that the client is malnourished. Nutritional deficits significantly delay the inflammatory and proliferative phases of healing.
F. History of malnutrition: Adequate protein, vitamins (A and C), and zinc are essential for collagen synthesis. A history of malnutrition suggests poor reserves for the healing process.
Correct Answer is C
Explanation
A. Mark the length to be inserted on the tube with tape.: This is done after the pathway is assessed but before insertion.
B. Place a water-based lubricant on the tip of the tube.: This is done immediately before insertion, not as the first step.
C. Compare the patency of the client's nares.: Following the Nursing Process (Assessment first), the nurse must determine which nostril is most patent to ensure the easiest passage for the tube.
D. Instruct the client to hyperextend her neck.: This is a position used during the initial insertion phase, but assessment of the nares must come first.
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