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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A Reason:

Turn the client every 4 hr. is incorrect. While repositioning is crucial for preventing pressure ulcers in immobile patients, turning the client every 4 hours might not directly address the issue of fecal incontinence or skin protection in the perineal area.

Choice B Reason:

Cleanse the perineal area with povidone-iodine solution is incorrect. Povidone-iodine solution might be too harsh for routine perineal care and can potentially irritate the skin. A gentler cleansing solution is typically recommended to avoid further skin irritation.

Choice C Reason:

Apply cornstarch powder to the perineal area is incorrect. Cornstarch powder might exacerbate moisture-related skin issues in the perineal area by creating a damp environment, potentially leading to skin maceration and worsening skin problems. It's not typically recommended for use in managing fecal incontinence.

Choice D Reason:

Place a moisture barrier ointment over the perineal area is correct. Using a moisture barrier ointment can help protect the skin from irritation and breakdown caused by prolonged exposure to fecal matter, reducing the risk of skin breakdown and discomfort.

A. Type 1 diabetes mellitus B. Orthostatic hypotension C. BMI of 24 D. Family history of osteoporosis

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.

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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?

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Naxlex Comprehensive Predictor Exams

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