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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. "I will empty my drainage bag once a day.": The bag should be emptied when it is half to two-thirds full, or at least every 8 hours, to prevent tension and bacterial growth.

B. "I will keep the drainage bag below the level of my waist.": Keeping the bag lower than the bladder ensures that gravity allows urine to flow out and prevents the backflow (reflux) of contaminated urine into the bladder.

C. "I will apply antiseptic ointment to the tip of my penis.": Routine use of antiseptic ointments at the meatus is not recommended and can actually increase the risk of infection by trapping bacteria.

D. "I will clamp the tube when I go for a walk.": The catheter should never be clamped without a specific medical order, as it causes urine to back up into the bladder and kidneys.

A. Photo identification B. Room number C. Facility-assigned identification number D. Diagnosis E. Date of birth

Correct Answer is ["A","C","E"]

Explanation

A. Photo identification: In many long-term care settings, a photo is used as a secondary identifier for clients who may be confused or non-verbal.

B. Room number: Room numbers are never used as identifiers because clients can be moved or transferred between rooms.

C. Facility-assigned identification number: This is a unique number assigned to the specific client upon admission.

D. Diagnosis: Multiple clients on a unit may share the same diagnosis (e.g., CHF or Diabetes).

E. Date of birth: This is a standard, unique identifier used in conjunction with the client's name.

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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?

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Naxlex Comprehensive Predictor Exams

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