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.
Place the drainage bag on the bed when transporting the client.
Use soap and water to provide perineal care.
Encourage the client to drink 3000 mL of fluid daily.
Change the indwelling urinary catheter tubing every 3 days.
Empty the drainage bag when it is half-full.
Correct Answer : A,C
A: Review the need for the indwelling urinary catheter daily.
This is correct because indwelling catheters should be removed as soon as possible to reduce the risk of urinary tract infection (UTI).
B: Place the drainage bag on the bed when transporting the client.
This is incorrect because the drainage bag should be kept below the level of the bladder and should not touch the floor to prevent the backflow of urine and contamination of the catheter.
C: Use soap and water to provide perineal care.
This is correct because soap and water can help to remove bacteria and debris from the meatus and prevent infection.
D: Encourage the client to drink 3000 mL of fluid daily.
This is incorrect because the client has a fluid restriction of 1000 mL daily due to heart failure. Excessive fluid intake can worsen the client’s condition and increase the workload of the heart.
E: Change the indwelling urinary catheter tubing every 3 days.
This is incorrect because changing the catheter tubing can increase the risk of infection by breaking the closed drainage system. The catheter tubing should only be changed when it is visibly soiled or malfunctioning.
F: Empty the drainage bag when it is half full.
This is incorrect because the drainage bag should be emptied at least every 8 hours or when it is one-third full to prevent back pressure and infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B.
Choice A reason: Atrial fibrillation is characterized by a rapid, irregular heartbeat and an absence of distinct P waves on the ECG, which is not indicated by the information provided.
Choice B reason: First-degree AV block is indicated by a prolonged PR interval without affecting the overall heart rate, aligning with the client’s PR interval of 0.24 seconds.
Choice C reason: Premature ventricular contraction would show an abnormal QRS complex on the ECG, which is not mentioned in the scenario.
Choice D reason: Sinus bradycardia is defined by a heart rate less than 60 bpm, which does not apply here as the client’s heart rate is 69/min, within the normal range of 60-100 bpm.
Correct Answer is D
Explanation
The correct answer is choice D. Speak directly to the client. This is because the nurse should establish eye contact and rapport with the client, not the interpreter, and show respect for the client’s culture and autonomy. The nurse should also use simple and clear language, avoid jargon and slang, and speak in short sentences.
Choice A is wrong because using gestures to convey meaning can be confusing or offensive to some cultures. The nurse should avoid relying on nonverbal communication and ask the interpreter for clarification if needed.
Choice B is wrong because pausing in the middle of sentences can disrupt the flow of communication and make it harder for the interpreter to translate accurately. The nurse should pause at the end of each complete thought or sentence to allow the interpreter to relay the information.
Choice C is wrong because speaking slowly when talking to the interpreter can imply that the interpreter is incompetent or unintelligent. The nurse should speak at a normal pace and tone, and allow enough time for the interpreter to translate.
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