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 A
Explanation
A. Acupuncture involves inserting needles into the skin, which can introduce infections. Herpes zoster (shingles) causes skin lesions and nerve pain, making acupuncture unsafe due to the risk of exacerbating the condition or spreading the virus.
B. Hypothyroidism does not affect the safety of acupuncture.
C. Obesity is not a contraindication but may require adjustments in acupuncture techniques.
D. Hypertension is not a contraindication unless the client has severe, uncontrolled hypertension.
Correct Answer is A
Explanation
A. A fetal heart rate (FHR) baseline of 170/min indicates fetal tachycardia, which could be due to maternal fever, dehydration, infection, or fetal distress. This requires immediate evaluation by the provider.
B. Early decelerations are a normal finding caused by fetal head compression and do not indicate distress.
C. A temperature of 37.4°C (99.3°F) is within the normal range and does not require reporting.
D. Contractions lasting 80 seconds are within an acceptable range during active labor (typically 60-90 seconds).
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