A nurse is caring for a client in the medical-surgical unit.

Exhibits

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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

The correct first action for the charge nurse to take in response to an increase in facility-acquired catheter infections is toidentify possible precipitating factors related to the infections. This is because understanding the root cause of the problem is crucial before implementing any changes or interventions. By identifying the factors contributing to the increase in infections, the nurse can then develop targeted strategies to address these specific issues.

Now, let’s discuss why the other options are not the first actions to take:

Schedule nursing staff training for infection control procedures: While training is important, it should be based on identified needs. Without first understanding the precipitating factors of the increased infections, the training may not address the actual issues at hand.
Meet with providers to discuss measures to decrease the infections: This could be a subsequent step after identifying the precipitating factors. Meeting with providers without concrete data or understanding of the problem may lead to ineffective solutions.
Revise the current policy for catheter care: Policy revision should be based on evidence and identified needs. It would be premature to revise policies without first understanding what factors are contributing to the increase in infections.

In summary, the first step in addressing a problem is always to understand its causes. Only then can effective solutions be developed and implemented.

A. Maintain a semi-Fowler’s position during testing B. Place tongue on the mouthpiece of the meter C. Blow into the meter as hard and quickly as possible D. Record the average of the readings

Correct Answer is C

Explanation

The correct answer is choice C. Blow into the meter as hard and quickly as possible.

This is because a peak flow meter measures how fast you can push air out of your lungs when you blow out as hard and as fast as you can.

This is called peak expiratory flow rate (PEFR) or peak expiratory flow (PEF). It shows how open the airways are in the lungs and can help detect early signs of worsening asthma.

Choice A is wrong because maintaining a semi-Fowler’s position during testing is not necessary. You can sit or stand up straight, but make sure you do it the same way each time.

Choice B is wrong because placing tongue on the mouthpiece of the meter can block the air flow and affect the accuracy of the measurement. You should close your lips tightly on the mouthpiece instead.

Choice D is wrong because recording the average of the readings is not recommended.

You should record the highest of the three readings on a sheet of paper, calendar or in your asthma diary. This is your daily peak flow.

Normal ranges for peak flow vary depending on age, height, gender and race. You can use a chart or calculator to find out your predicted normal peak flow based on these factors. However, it is more important to find out your personal best peak flow by performing peak flow testing twice a day for two weeks when your asthma is under good control. Your personal best peak flow will be used to create your asthma action plan with your healthcare provider.

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A nurse is caring for a client in the medical-surgical unit. Exhibits Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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A nurse is caring for a client in the medical-surgical unit.

Exhibits

Which of the following actions should the nurse take to decrease the risks for urinary tract infection for this client?

Select all that apply.