A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?
Coil the tubing on the bed above the collection bag.
Instruct the client to hold the drainage bag at waist height when ambulating.
Collect a sterile specimen from the urinary drainage bag.
Secure the tubing with adhesive tape to the lower abdomen
The Correct Answer is D
A) Coiling the tubing on the bed above the collection bag is incorrect because it can cause urine to flow back into the bladder, increasing the risk of infection and compromising the effectiveness of the drainage system. The tubing should be kept below the level of the bladder to ensure proper drainage.
B) Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which could lead to a urinary tract infection (UTI).
C) Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe.
D) Securing the tubing with adhesive tape to the lower abdomen is correct because it helps prevent accidental pulling or tugging on the catheter, which could cause discomfort or dislodgement. Properly securing the tubing also helps maintain a continuous flow of urine and reduces the risk of infection.
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Related Questions
Correct Answer is D
Explanation
a.Frequent bathing can actually worsen dry, itchy skin as it can strip away the natural oils that help moisturize the skin. Instead, the nurse should encourage the client to limit bathing to shorter durations using lukewarm water and gentle, fragrance-free cleansers.
b.Powder may not provide significant relief for dry, itchy skin and can potentially irritate the skin further. It is best to focus on moisturizing and hydrating the skin to alleviate the symptoms.
c.While this might seem helpful, oils in the bath can create a slippery surface, posing a fall risk, especially for older adults. Additionally, oils might not provide sufficient hydration to the skin and could leave a residue that is not always beneficial.
d.Dry, itchy skin is a common concern among older adults, and it can be exacerbated by low humidity levels. Placing a humidifier in the client's room helps to increase the moisture content in the air, which can alleviate dryness and itchiness. The increased humidity can help prevent the skin from becoming overly dry and can provide relief from the symptoms.
Correct Answer is A
Explanation
An oxygen saturation level of 90% is below the normal range and indicates inadequate oxygenation. This finding could indicate respiratory compromise or impaired lung function, which may require further assessment and intervention before allowing the client to ambulate.
The respiratory rate of 20 breaths per minute, apical pulse rate of 88 beats per minute, and oral temperature of 37.6°C (99.7°F) are within the expected range and do not raise immediate concerns that require reporting to the charge nurse prior to ambulation.
However, the nurse should continue to monitor these vital signs during and after ambulation to ensure stability.
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