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 D
Explanation
Choice A Reason:
Placing the bed in the lowest position before logrolling the client is incorrect. Lowering the bed position isn't directly related to the safety or comfort of the client during logrolling. It's more important to focus on proper body alignment and support for the surgical site.
Choice B Reason:
Placing the client in semi-Fowler's position prior to logrolling is incorrect. Semi-Fowler's position (a reclined position with the head of the bed elevated at a 30-45-degree angle) might be used for comfort, but it's not specifically necessary before logrolling, which is a technique used to move the client while maintaining spinal alignment.
Choice C Reason:
Placing the client's arms above her head prior to logrolling is incorrect. Placing the client's arms above the head isn't typically necessary or recommended before logrolling a postoperative client. It's crucial to prioritize maintaining proper body alignment and minimizing stress on the surgical site during movement.
Choice D Reason:
Placing a pillow between the client's legs prior to logrolling is correct. This action helps maintain proper alignment of the spine and reduces pressure on the surgical site during logrolling. Placing a pillow between the legs provides support and helps prevent excessive twisting or stress on the back.
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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