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.
Use soap and water to provide perineal care.
Place the drainage bag on the bed when transporting the client.
Encourage the client to drink 3000 mL of fluid daily,
Empty the drainage bag when it is half full
Revive the need for the indwelling urinary catheter daily
Change the indwelling urinary catheter tubing every 3 days
Correct Answer : A,D,E
A. Proper perineal hygiene reduces the risk of catheter-associated urinary tract infections (CAUTIs). Using soap and water is recommended over antiseptics, as excessive antiseptic use may disrupt normal flora.
B. The drainage bag should always be kept below the bladder level to prevent urine backflow, which increases UTI risk. The bag should be hung from a non-movable part of the bed or wheelchair.
C. The client has heart failure and is already on a fluid restriction of 1000 mL/day. Encouraging excessive fluid intake could worsen fluid overload and heart failure symptoms.
D. Urinary catheter bags should be emptied regularly (preferably when half full) to prevent urine backflow, which increases the risk of infection. Overfilled bags can create backpressure and promote bacterial growth.
E. Indwelling catheters should be removed as soon as possible to reduce the risk of CAUTIs. Daily assessment ensures that the catheter is removed when no longer necessary.
F. Routine changing of catheter tubing is not recommended unless there are signs of infection, leakage, or blockage. Frequent changes can introduce bacteria and increase infection risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect – Warfarin is generally safe while breastfeeding, as it does not significantly transfer into breast milk.
B. Incorrect – Sodium phosphate is a common bowel prep before a colonoscopy. No immediate concerns.
C. Correct – A Mantoux test (PPD skin test) with induration could indicate tuberculosis (TB) infection. The size of the induration (not redness) determines if the result is positive and requires further testing.
D. Incorrect – Bumetanide is a loop diuretic, and increased urination is an expected effect.
Correct Answer is B
Explanation
A. Documenting the client's condition every 15 minutes is too frequent for standard restraint protocols.
B. Protocols typically require that restraints be removed at least every 2–4 hours for assessment of the client's condition, skin integrity, and to provide a period of unrestrained movement.
C. PRN restraint prescriptions are not standard practice; restraints should be prescribed only when absolutely necessary and under strict guidelines.
D. Restraints should be attached to the bed frame or other secure point, not the side rails, to ensure safety and prevent injury.
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