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:
Recheck the client's SaO2 level after having the client cough and clear their throat is correct. This action is crucial to ensure the accuracy of the SaO2 reading. Sometimes, minor obstructions or secretions in the airway can momentarily affect the oxygen saturation readings. Having the client cough and clear their throat may help improve the SaO2 readings by clearing any temporary blockages.
Choice B Reason:
Review the client's most recent SaO2 level in the medical record is incorrect. While reviewing the client's history is important, the immediate priority is to verify the current SaO2 level for accuracy before taking further action.
Choice C Reason:
Notify the charge nurse of the client's condition is incorrect. While it might eventually be necessary to inform other healthcare team members, the immediate action should focus on rechecking the SaO2 level to ensure the client's current oxygen saturation status.
Choice D Reason:
Check the client's medical records to see which medications were recently administered is incorrect. Knowing the client's recent medications is important for assessment, but it may not directly address the current situation of shortness of breath and low oxygen saturation. Rechecking the SaO2 level takes precedence in this acute situation.
Correct Answer is B
Explanation
Choice A Reason:
The stoma bleeds lightly when touched is incorrect. Some minor bleeding during the initial postoperative period is expected due to surgical trauma. Light bleeding when touched might not be unusual in the immediate days following colostomy placement.
Choice B Reason:
The stoma appears dark in color is correct. A dark-colored stoma could indicate compromised blood supply or ischemia, which is a concerning finding postoperatively. It's crucial to report this change in color promptly to the provider for further evaluation and intervention.
Choice CReason:
The stoma is draining a small amount of liquid stool is incorrect. In the early postoperative period, drainage of liquid stool from the stoma is normal. The digestive system needs time to adapt to the new anatomy created by the colostomy, and initially, the stool consistency might be liquid before it starts to normalize.
Choice DReason:
The stoma protrudes slightly from the abdomen is incorrect. A slightly protruding stoma is a common and expected finding after colostomy surgery. It's often a normal part of the healing process as the stoma settles and adjusts.
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