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.
Encourage the client to drink 3000 mL of fluid daily.
Review the need for the indwelling urinary catheter daily.
Empty the drainage bag when it is half-full.
Use soap and water to provide perineal care.
Place the drainage bag on the bed when transporting the client.
Change the indwelling urinary catheter tubing every 3 days.
Correct Answer : B,C,D
Rationale:
A. Encourage the client to drink 3000 mL of fluid daily: This is contraindicated because the client has heart failure with signs of fluid volume excess (crackles and 3+ pitting edema). Increasing fluid intake could worsen fluid overload.
B. Review the need for the indwelling urinary catheter daily: Daily assessment of catheter necessity allows for timely removal when it is no longer needed, which significantly decreases the risk of catheter-associated urinary tract infections (CAUTIs).
C. Empty the drainage bag when it is half-full: Keeping the drainage bag from becoming overfilled prevents urine backflow into the bladder, which can introduce bacteria and increase infection risk. Regular emptying is a key preventive measure.
D. Use soap and water to provide perineal care: Proper perineal hygiene with mild soap and water helps remove bacteria and maintain skin integrity, reducing the risk of urinary tract infection, especially in incontinent clients.
E. Place the drainage bag on the bed when transporting the client: The drainage bag should always remain below the level of the bladder and off the bed to prevent backflow of urine, which can introduce bacteria and increase infection risk.
F. Change the indwelling urinary catheter tubing every 3 days: Routine scheduled tubing changes are not recommended, as unnecessary manipulation of the system can increase infection risk. Tubing should only be changed when clinically indicated (e.g., contamination, obstruction).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Osteoarthritis: Osteoarthritis affects joint function and mobility but does not directly increase the risk for heart failure. While it can limit physical activity, it is not a primary cardiovascular risk factor.
B. Alcohol use disorder: Chronic excessive alcohol consumption can lead to cardiomyopathy, hypertension, and arrhythmias, all of which increase the risk for heart failure. Alcohol use disorder is a well-established modifiable risk factor for cardiac dysfunction.
C. Sleep apnea: Obstructive sleep apnea contributes to intermittent hypoxia, sympathetic nervous system activation, and increased blood pressure, all of which can promote the development of heart failure. Screening and management of sleep apnea are important preventive measures.
D. Diabetes mellitus: Diabetes increases the risk of heart failure through mechanisms such as accelerated atherosclerosis, microvascular damage, and diabetic cardiomyopathy. Poor glycemic control further elevates cardiovascular risk.
E. Hypotension: Hypotension, or low blood pressure, does not increase the risk of heart failure; in fact, hypertension is a more significant risk factor. Chronic hypotension can cause other issues, but it is not directly linked to heart failure development.
Correct Answer is B
Explanation
A. Furosemide: Furosemide is a loop diuretic that promotes potassium excretion. It does not need to be withheld for a mildly elevated potassium level; in fact, it may help lower potassium levels in hyperkalemia.
B. Spironolactone: Spironolactone is a potassium-sparing diuretic that can increase serum potassium. With a level of 5.2 mEq/L, administering spironolactone could worsen hyperkalemia and increase the risk of cardiac complications, so the dose should be withheld and the provider notified.
C. Metoprolol: Metoprolol, a beta-blocker, does not typically raise potassium levels significantly. While beta-blockers can slightly affect potassium, withholding is not indicated solely based on a potassium level of 5.2 mEq/L.
D. Atorvastatin: Atorvastatin, a lipid-lowering agent, has no effect on serum potassium levels and does not need to be withheld in this situation. It can be continued safely.
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