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?

Secure the tubing with adhesive tape to the lower abdomen.

Instruct the client to hold the drainage bag at waist height when ambulating

Coil the tubing on the bed above the collection bag.

Collect a sterile specimen from the urinary drainage bag

Answer and Explanation

The Correct Answer is A

A. Secure the tubing with adhesive tape to the lower abdomen: Properly securing the catheter tubing prevents tension on the catheter, reduces the risk of accidental dislodgment, and helps maintain a closed drainage system, which decreases the risk of infection.

B. Instruct the client to hold the drainage bag at waist height when ambulating: The drainage bag should always be kept below the level of the bladder to maintain proper urine flow and prevent backflow, which increases the risk of infection. Holding it at waist height is unsafe.

C. Coil the tubing on the bed above the collection bag: Placing tubing above the collection bag can allow urine to flow back toward the bladder, increasing the risk of urinary tract infection. Tubing should remain below bladder level.

D. Collect a sterile specimen from the urinary drainage bag: Sterile urine specimens should be obtained from a sampling port on the catheter using aseptic technique, not directly from the drainage bag, to avoid contamination.

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Correct Answer is C

Explanation

A. "Why do you feel the staff is the FBI”: Asking “why” can sound confrontational and may make the client feel interrogated or defensive. It can increase anxiety and does not provide emotional support. This approach is not therapeutic when a client is experiencing a fixed delusion.

B. "The psychiatric staff is not FBI. They are here to help you.": Directly contradicting the client’s delusion can increase mistrust and agitation in a client with paranoid schizophrenia. This response challenges the belief without acknowledging the client’s emotional experience, which can damage rapport.

C. "This must be very frightening for you, let's talk more about it.": This response acknowledges the client’s feelings without validating the delusion itself. It conveys empathy, reduces anxiety, and encourages further communication. This therapeutic approach helps build trust while gently redirecting focus to the client’s emotional state.

D. "What makes you think the staff is following you”: Although more open-ended than option A, this question encourages the client to further elaborate on the delusion. It risks reinforcing the false belief rather than focusing on emotional support and reality-based care.

A. Pain rating of 4 on a scale of 0 to 10 B. Temperature of 37.2° C (99.0°F) C. increased urinary output D. Elevated WBC count

Correct Answer is D

Explanation

A. Pain rating of 4 on a scale of 0 to 10: Mild to moderate pain is expected in the early postoperative period due to surgical trauma. While pain should be monitored, a rating of 4 is not specific for infection and can be considered within normal postoperative discomfort.

B. Temperature of 37.2° C (99.0°F): A slightly elevated temperature within the normal range is common after surgery due to inflammatory response. It does not necessarily indicate infection unless it continues to rise or is accompanied by other systemic signs.

C. Increased urinary output: Increased urine output is generally a positive sign of adequate renal perfusion and fluid balance. It is not indicative of infection and may instead reflect normal postoperative recovery or fluid administration.

D. Elevated WBC count: Leukocytosis is a key laboratory indicator of infection. An elevated white blood cell count suggests an inflammatory or infectious process, which is particularly concerning in the postoperative period and warrants further assessment and intervention.

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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?

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