A nurse is caring for a client who had an indwelling urinary catheter inserted 3 days ago. Which of the following actions should the nurse take?
Obtain urine from the drainage bag if a urinary specimen is required.
Use a catheter securing device to hold the catheter in place.
Position the drainage bag higher than the client's bladder.
Change the catheter bag every 3 days and as needed.
The Correct Answer is B
Choice A Reason:
Obtaining urine from the drainage bag if a urinary specimen is required is incorrect.
While obtaining urine from the drainage bag might seem practical for specimen collection, it's not the recommended method due to potential contamination of the specimen. A sterile sampling port or aspirating urine from the catheter tubing is a more appropriate technique.
Choice B Reason:
Using a catheter securing device to hold the catheter in place is correct. Securing the catheter with a proper securing device helps prevent unnecessary movement or tension on the catheter, reducing the risk of trauma to the urinary tract and ensuring stability for the catheter.
Choice C Reason:
Positioning the drainage bag higher than the client's bladder is incorrect. Positioning the drainage bag higher than the bladder can lead to backflow or reflux of urine, increasing the risk of urinary tract infections. The drainage bag should be placed below the level of the bladder to facilitate proper drainage.
Choice D Reason:
Changing the catheter bag every 3 days and as needed is incorrect. Routine changing of catheter bags every three days without clinical indication for changing can increase the risk of introducing infection. Catheter bags are changed based on clinical indications or when they are soiled or damaged, not on a fixed time schedule.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Type 1 diabetes mellitus is correct. individuals with diabetes, especially Type 1 diabetes mellitus, are at an increased risk of developing cardiovascular disease. Diabetes can contribute to atherosclerosis, increasing the risk of heart disease, stroke, and other cardiovascular complications.
Choice B Reason:
Orthostatic hypotension is not correct. It refers to a drop-in blood pressure when moving from a lying to a standing position and is more related to blood pressure regulation than a direct risk factor for cardiovascular disease.
Choice C Reason:
A BMI of 24 is incorrect because it is within the normal range is not typically considered a significant risk factor for cardiovascular disease. However, higher BMIs, especially in the overweight or obese categories, can increase the risk.
Choice D Reason:
A family history of osteoporosis is incorrect because it is related to bone health and susceptibility to osteoporosis, a condition characterized by weak and brittle bones. While it's an important health consideration, it's not directly linked to cardiovascular disease risk.
Correct Answer is E,C,B,D,A
Explanation
E. Disconnect the tube from the suction device:
Before starting the removal process, it's essential to disconnect the tube from any suction to prevent discomfort or injury to the client during removal.
C. Instill 50 mL of air into the tube:
Instilling air into the tube helps clear any residual contents and lubricates the tube, making it easier and more comfortable to remove.
B. Ask the client to take a deep breath:
Instructing the client to take a deep breath helps relax the throat and upper esophageal muscles, making the removal process smoother and potentially less uncomfortable.
D. Pinch and withdraw the tube:
Withdrawing the tube while the client holds their breath aids in a controlled removal, minimizing discomfort or risk of aspiration.
A. Apply clean gloves:
Lastly, applying clean gloves ensures infection control and maintains cleanliness during the removal process, preventing any potential contamination.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.