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 A

Explanation

Choice A Reason:

Measuring the intake and output of a client who has received furosemide is correct. This task involves recording and measuring fluid intake and output, which is typically within the scope of practice for assistive personnel. It requires accurate documentation and doesn't involve making clinical judgments.

Choice B Reason:

Reinforcing teaching with a client about crutch-gait walking is incorrect. Teaching and instructing clients about specific medical procedures or techniques usually require specialized knowledge and assessment skills, typically within the nurse's scope of practice.

Choice C Reason:

Checking a client's peripheral IV site for redness or swelling is incorrect. Assessing for redness or swelling at an IV site involves clinical judgment and assessment skills to identify potential complications. This task is better suited for a licensed nurse who can interpret findings and take appropriate action if needed.

Choice D Reason:

Assessing the pain level of a client who has received acetaminophen is incorrect. Assessing pain levels involves subjective interpretation and understanding of pain scales, which generally falls under the scope of licensed healthcare providers who can evaluate and manage pain interventions based on assessments.

A. "We can discuss this when you're not feeling overwhelmed." B. "I understand how you feel. I've had a relative go through the same thing." C. "Have you tried taking your partner with you when you go out?" D. "Tell me more about your expectations."

Correct Answer is D

Explanation

Choice A Reason:

"We can discuss this when you're not feeling overwhelmed." Is incorrect. This response acknowledges the partner's feelings but doesn't directly address their concern about missing social outings. It offers to revisit the topic later, which might be helpful, but it doesn't provide immediate support or suggestions.

Choice B Reason:

"I understand how you feel. I've had a relative go through the same thing." Is incorrect. While expressing empathy is essential, comparing experiences might inadvertently minimize the partner's feelings. Each situation is unique, and the partner might need specific advice or support tailored to their circumstances.

Choice C Reason:

"Have you tried taking your partner with you when you go out?" is incorrect. This response suggests a potential solution by proposing involving the client with Alzheimer's in social outings. However, in advanced stages, this might not always be feasible or suitable due to the nature of the condition. It's essential to be sensitive to the client's needs and abilities.

Choice D Reason:

"Tell me more about your expectations." Is correct. This response invites the partner to share more about their feelings and desires without assuming a solution. It opens a dialogue to understand the partner's concerns and expectations better, allowing the nurse to offer appropriate support or guidance.

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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?

Nursing Test Bank

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