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 D

Explanation

A. "We will wrap our baby in a blanket under the car seat straps when it is cold out.": Placing a blanket under the straps can prevent proper restraint and reduce the effectiveness of the harness, increasing the risk of injury during a crash. Blankets should go over the secured straps instead.

B. "We will make sure to activate the air bag when we place the car seat in the front passenger seat.": Airbags can cause serious injury or death to infants in the event of a collision. Infants should always ride in the back seat, away from active airbags.

C. "We will switch our baby's car seat to forward facing when they turn one.": Current safety guidelines recommend keeping infants in a rear-facing car seat until at least 2 years of age or until they reach the maximum height and weight allowed by the car seat manufacturer.

D. "We will check the temperature of the car seat surface before placing our baby in the seat when it is hot out.": Checking the car seat’s surface temperature helps prevent burns from hot straps or seat material. This demonstrates understanding of infant safety measures during car seat use.

A. “It is your choice to share personal information during group therapy.” B. "I will only discuss your medical information with the health care team." C. “I will be truthful when answering questions about your treatment” D. "The nursing staff here will provide you with nonjudgmental care”

Correct Answer is A

Explanation

A. “It is your choice to share personal information during group therapy.”: This statement supports client autonomy by emphasizing the client’s right to make decisions about their own participation and what personal information to disclose. Respecting autonomy involves allowing clients to make informed choices about their care and interactions.

B. "I will only discuss your medical information with the health care team.": This reflects the ethical principle of confidentiality, protecting privacy, but does not directly address autonomy.

C. “I will be truthful when answering questions about your treatment”: Truthfulness relates to veracity, ensuring honesty in the nurse-client relationship, but does not specifically promote autonomy.

D. "The nursing staff here will provide you with nonjudgmental care”: Providing nonjudgmental care supports beneficence and a therapeutic environment but does not directly empower the client to make their own decisions.

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Body system	Findings
Head, Eyes, Ears, Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Weight gain
Hematologic	Increased bruising Increased bleeding tendency Insomnia
Genitourinary	Darkening of the urine Urinary frequency

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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