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:
This is the correct action. A filter needle should be used when drawing medication from an ampule to prevent glass particles from being aspirated into the syringe and subsequently administered to the patient.
Choice B Reason:
Adding 0.5 ml of diluent to the medication is incorrect. Adding diluent to medication from an ampule is not a standard practice. Ampules usually contain pre-measured doses of medication and are designed for direct withdrawal without dilution. Adding diluent could alter the concentration and effectiveness of the medication.
Choice C Reason:
This is not necessary. Once the ampule is opened, it should be handled with care to avoid contamination, but cleansing the tip with an alcohol swab is not a standard practice since it does not effectively remove glass particles.
Choice D Reason:
This is incorrect. Ampules are not pressurized containers, and injecting air into an ampule is unnecessary and could cause the medication to spill out or create bubbles that interfere with accurate dosing.
Correct Answer is C
Explanation
Choice AReason:
Encouraging the client to abstain from distracting activities is incorrect. Engaging in distracting activities can actually be beneficial in pain management. It can redirect the client's focus away from the pain, potentially reducing its intensity.
Choice BReason:
Ensuring that the client's room is kept at a cool temperature is incorrect.
While temperature can influence comfort, maintaining a cool room might not directly address or alleviate the client's pain.
Choice C Reason:
Playing music in the client's room is correct. Music therapy is a nonpharmacological intervention that can effectively help in managing pain. Calming or soothing music can distract the client from pain, reduce anxiety, and promote relaxation, potentially reducing the perception of pain.
Choice D Reason:
Keep the client's room well-lit is incorrect. The lighting in the room might not significantly impact pain levels. Some individuals might prefer dim lighting for relaxation, but it might not directly influence pain perception.
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