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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E","F"]
Explanation
c, d, e, and f.
a.An advance directive does not automatically discontinue further care. It simply provides guidance to healthcare providers on the client's wishes for medical treatment. It is important for the nurse to explain this to the client and ensure that they understand the purpose of an advance directive.
b. While nurses can provide information and support the client in understanding the importance of having a power of attorney for healthcare, initiating such documents is typically not within the scope of nursing practice. This task usually requires legal guidance and formalities that go beyond nursing responsibilities.
c.Accurate documentation is crucial in healthcare. If a provider discusses do-not-resuscitate (DNR) status with a client, it must be documented in the client's medical record to ensure that all healthcare team members are aware of the client’s wishes.
d. Provide the client with writen information about advance directives: It is important for the nurse to provide the client with writen information about advance directives, including their rights and options for creating an advance directive. This information should be provided in a clear and understandable manner.
e. Communicate advance directives status via the medical record and shift report: The nurse should communicate the client's advance directives status to other members of the healthcare team via the medical record and shift report. This ensures that everyone involved in the client's care is aware of the client's wishes and can provide care that is consistent with those wishes.
f. Instruct the client that an advance directive is a legal document and must be honored by care providers: The nurse should instruct the client that an advance directive is a legal document that must be honored by care providers. This ensures that the client understands the importance of their advance directive and can advocate for their wishes if necessary.
Correct Answer is D
Explanation
Understanding the literacy level of the older adults is crucial for developing an effective education program. It helps the nurse tailor the content, language, and teaching methods to ensure that the material is accessible and understandable to the participants. By assessing their literacy level, the nurse can identify any potential barriers to learning and make appropriate adjustments to promote effective communication and comprehension.
Once the literacy level is determined, the nurse can then proceed with the other actions, such as establishing learning outcomes, scheduling a time to implement the program, and creating handouts that are suitable for the participants' literacy level. However, determining the literacy level should be the first step in order to create an inclusive and effective educational experience for the older adults.
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