A nurse is caring for a client in the medical-surgical unit.
Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client? Select all that apply.
Review the need for the indwelling urinary catheter daily.
Encourage the client to drink 3000 mL of fluid daily.
Place the drainage bag on the bed when transporting the client.
Empty the drainage bag when it is half-full.
Change the indwelling urinary catheter tubing every 3 days.
Use soap and water to provide perineal care.
Correct Answer : A,B,F
Rationale
A. Review the need for the indwelling urinary catheter daily.
One of the most effective strategies to prevent UTIs is avoiding unnecessary catheterization. The nurse should regularly assess whether the catheter is still necessary and remove it as soon as possible. Keeping a catheter in place longer than needed increases the risk of infection.
B. Encourage the client to drink 3000 mL of fluid daily.
Increasing fluid intake is generally a good measure to help flush the urinary tract, reducing the concentration of bacteria and preventing infections. However, for clients with heart failure, excessive fluid intake can exacerbate fluid overload, leading to pulmonary edema and worsened symptoms of heart failure. Therefore, the nurse should consult the healthcare provider before recommending a specific amount of fluid intake (such as 3000 mL). The nurse should ensure that the client’s fluid intake is balanced with their heart failure management plan.
C. Place the drainage bag on the bed when transporting the client.
The drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which can lead to infections. Placing the drainage bag on the bed when transporting the client would increase the risk of urine reflux, potentially leading to a UTI. The bag should be secured properly and kept off the bed or floor during transport.
D. Empty the drainage bag when it is half-full.
The drainage bag should be emptied when it is full (typically around 2/3 to 3/4 full) to prevent overfilling, which can increase the risk of backflow or spillage. Emptying the bag when it is half-full may lead to unnecessary handling of the catheter and increases the risk of contamination. It’s important to empty the bag regularly, but not excessively often.
E. Change the indwelling urinary catheter tubing every 3 days.
There is no need to change the indwelling catheter tubing on a regular basis unless there is a specific indication (e.g., blockage or infection). Frequent changes of the catheter tubing increase the risk of introducing bacteria. According to best practice guidelines, the catheter should be changed only when necessary, not routinely every 3 days.
F. Use soap and water to provide perineal care.
Regular and gentle perineal care with soap and water is crucial for reducing the risk of UTIs. The perineal area should be cleaned daily and after any incontinence episodes to minimize bacterial contamination of the catheter and urinary tract. It’s important to avoid harsh chemicals, which could irritate the skin and urinary tract.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A laissez-faire leader avoids lecturing or providing structured guidance.
B. A laissez-faire leader typically does not impose rules of silence but allows the group to engage freely.
C. While group members may participate, decisions about what to learn are not typically voted on in this style.
D. The laissez-faire leadership style is characterized by allowing group members to discuss topics freely without much interference.
Correct Answer is ["A","C","E","F","H"]
Explanation
A. Smoking marijuana to clear their mind
Using marijuana to cope with emotional pain or trauma is concerning. It suggests that the client may be turning to substances to manage their stress, anxiety, or trauma-related symptoms, which could lead to substance use disorder. It is important to address the substance use as it may hinder the healing process, especially given the trauma the client has experienced.
B. BP 122/80 mm Hg
This blood pressure reading is within the normal range for a 16-year-old. A blood pressure of 120/80 mm Hg or lower is generally considered normal for adolescents, so there is no immediate need for follow-up regarding this finding. This vital sign does not indicate an urgent issue.
C. Witnessing their family's death
Witnessing the violent deaths of close family members is a major traumatic event that can lead to post- traumatic stress disorder (PTSD), complicated grief, or other mental health issues. This experience is significant and requires immediate follow-up to assess how the client is processing the trauma and to ensure they are receiving appropriate mental health support, such as therapy or counseling.
D. Attends school regularly
While it's important to monitor the client’s social and academic functioning, attending school regularly is a positive indicator. The client is able to continue their education despite their trauma, which is a sign of resilience. However, this finding does not require immediate follow-up, but ongoing assessment may be needed to evaluate if there are any underlying issues affecting their school performance or social interactions.
E. Client experiences nightmares
Nightmares, particularly those related to a traumatic event, are a common symptom of post-traumatic stress disorder (PTSD). Since the client witnessed the traumatic deaths of their family members, this could be part of a larger pattern of distress. Follow-up is needed to evaluate the severity of the nightmares and determine whether the client needs trauma-focused therapy or other interventions to address potential PTSD symptoms.
F. Startles easily during thunderstorms
This is a common symptom of hypervigilance, which is associated with PTSD or acute stress disorder (ASD) following trauma. The client’s startle response, particularly in response to thunderstorms (which could be a trigger), warrants immediate follow-up. The nurse should assess the client's emotional response to stimuli and provide guidance on managing triggers, as well as explore whether the client needs therapy or trauma-informed care.
G. Heart rate 99/min
A heart rate of 99 beats per minute is within the normal range for adolescents and is not concerning on its own. While anxiety or stress could cause a mild increase in heart rate, this finding does not require immediate intervention unless there are other signs of distress, such as chest pain or difficulty breathing.
H. Caregiver reporting client acting differently than usual
A change in behavior, as reported by the caregiver, is concerning. It may indicate that the client is struggling emotionally or mentally, particularly after experiencing such a traumatic loss. This behavior could be linked to depression, anxiety, or trauma-related symptoms, and therefore requires immediate follow-up to assess the client's mental health and ensure that they are receiving appropriate support.
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