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).
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Related Questions
Correct Answer is D
Explanation
A. Encourage exercise 1 hr prior to sleep: Vigorous exercise immediately before bedtime can increase alertness and delay sleep onset. Exercise is best scheduled earlier in the day to promote better sleep quality.
B. Provide a warm cup of coffee 30 min before bedtime: Caffeine is a stimulant that can interfere with the ability to fall and stay asleep. Offering coffee close to bedtime is counterproductive to promoting sleep.
C. Turn on the client's television at bedtime: Television and other electronic devices emit light and provide stimulation that can disrupt circadian rhythms and inhibit melatonin release, making it harder to fall asleep.
D. Encourage the client to take a warm bath before bedtime: A warm bath helps relax muscles and promotes a decrease in core body temperature afterward, which can facilitate sleep onset. This is an effective, nonpharmacologic intervention to improve sleep quality.
Correct Answer is A
Explanation
A. Depression: Selegiline transdermal patches are indicated for the treatment of major depressive disorder. As a selective monoamine oxidase-B (MAO-B) inhibitor, it increases the availability of neurotransmitters such as dopamine, which can improve depressive symptoms in adults.
B. Anxiety: While selegiline may have indirect effects on mood, it is not primarily indicated for treating anxiety disorders. Anxiety may require other pharmacologic or therapeutic interventions specifically targeted to anxiety symptoms.
C. Tardive dyskinesia: Tardive dyskinesia is a movement disorder often associated with long-term antipsychotic use. Selegiline does not treat or prevent tardive dyskinesia; it is not indicated for movement disorder management in this context.
D. Bipolar mania: Selegiline is not indicated for the management of bipolar disorder or acute manic episodes. Treating mania typically involves mood stabilizers or antipsychotics rather than MAO-B inhibitors.
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