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:
"Encourage your partner to eat three large meals each day." Is incorrect. At the end of life, a patient's appetite might decrease, and they may not tolerate large meals. Encouraging large meals can cause discomfort or be inappropriate for their condition.
Choice B Reason:
"We will use an electric blanket to keep your partner warm." Is incorrect. While maintaining comfort is important, the use of an electric blanket might not be suitable as the patient's circulation and ability to regulate body temperature might be compromised.
Choice C Reason:
"Opioids will be restricted if your partner develops respiratory distress." Is incorrect.
Opioids can be appropriate for managing symptoms like pain or dyspnea at the end of life. Restricting opioids solely due to the risk of respiratory distress might hinder adequate symptom management. The use of opioids should be based on individual patient needs and careful assessment by healthcare providers.
Choice D Reason:
"Assume your partner can hear you, even if they do not respond." Is correct. This statement encourages communication and acknowledges the possibility that the patient might still be able to perceive their surroundings, even if they are not responsive. It supports the importance of providing emotional support and communication during the end-of-life process.
Correct Answer is ["A","B","C","D","E"]
Explanation
1. Unlock and remove the inner cannula (Step C). This is the initial step because it allows access to the inner cannula for cleaning. Removing it enables further cleaning of the inner cannula and ensures proper hygiene of the tracheostomy.
2. Scrub the inside and outside of the inner cannula with a small brush (Step D). Once the inner cannula is removed, it should be cleaned thoroughly to remove any secretions or debris. Scrubbing with a small brush helps in effectively cleaning both the inside and outside surfaces.
3. Wipe the inside of the inner cannula with a folded pipe cleaner (Step E). Using a pipe cleaner helps to reach areas that a brush might not access easily. It further ensures the removal of any remaining secretions or buildup inside the inner cannula.
4. Cleanse the stoma site with 0.9% sodium chloride solution (Step B). After addressing the inner cannula, the nurse moves to clean the stoma site to prevent infection or irritation. This step ensures the area around the tracheostomy is clean and free from contaminants.
5.Pour 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin (Step A). Lastly, preparing the sterile basin with the saline solution should be done at the start to ensure it's ready for use during the cleaning process. This solution will be utilized for cleaning the stoma site in step B and may also be needed for moistening the brush or pipe cleaner during steps D and E.
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