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 choice B. Fish. Fish is a good source of protein and omega-3 fatty acids, which can help lower blood pressure, reduce inflammation, and prevent blood clots. Fish is also low in sodium, which is important for people with hypertension, as excess sodium can raise blood pressure by retaining fluid in the body. Fish is part of the DASH diet, which stands for Dietary Approaches to Stop Hypertension, and is a healthy eating plan that emphasizes fruits, vegetables, whole grains, low-fat dairy, nuts, seeds, legumes, and lean meats.
Choice A. Cheese is wrong because cheese is high in sodium and saturated fat, which can increase blood pressure and cholesterol levels.
Cheese should be limited or avoided by people with hypertension.
Choice C. Red meat is wrong because red meat is also high in sodium and saturated fat, as well as cholesterol, which can contribute to hypertension and heart disease.
Red meat should be eaten sparingly or replaced by leaner sources of protein like fish, poultry, or beans.
Choice D. Canned black beans are wrong because canned black beans are high in sodium, as most canned foods are preserved with salt. Canned black beans should be rinsed well before eating or replaced by dried or cooked black beans, which are lower in sodium and high in fiber, potassium, magnesium, and calcium, which are beneficial for blood pressure control.
Correct Answer is B
Explanation
The correct answer is choice B. The nurse should sit in a chair next to the bed to place the client at ease. This position allows the nurse to maintain eye contact, show interest, and respect the client’s personal space. Sitting on the bed next to the client (choice A) is wrong because it invades the client’s privacy and comfort zone. Standing at the side of the bed (choice C) or at the foot of the bed (choice D) is wrong because it creates a power imbalance and may intimidate the client.
The nurse should also consider the client’s condition and preferences when choosing a position for the interview. For example, a client who is on bedrest may have difficulty hearing or seeing the nurse if they are too far away or at an awkward angle.
Therefore, the nurse should adjust their position accordingly and ask the client if they are comfortable with it.
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