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 C
Explanation
Effleurage is a massage technique commonly used during labor to provide comfort and relaxation. It involves using gentle, rhythmic stroking movements on the abdomen during contractions. This technique can help relieve tension, promote relaxation, and provide distraction from the intensity of the contractions.
Deep breathing techniques are often used during labor to promote relaxation and manage pain. However, this instruction does not specifically relate to effleurage.
Focusing on an object in the room, such as a focal point, can be a helpful technique during labor to redirect attention and manage pain. However, this instruction does not specifically relate to effleurage.
Applying pressure to the sacral area can help alleviate back pain during labor. However, this instruction describes the use of a tennis ball and is not specifically related to effleurage.
Correct Answer is D
Explanation
Blurred vision in the third trimester of pregnancy can be a potential sign of preeclampsia, a serious condition characterized by high blood pressure and organ damage.
Shortness of breath when climbing stairs is a common symptom in the third trimester as the growing uterus puts pressure on the diaphragm and limits lung expansion. While it is important to monitor the client's respiratory status, it is not an immediate cause for concern unless accompanied by severe or persistent shortness of breath.
Leukorrhea refers to an increase in vaginal discharge during pregnancy, which is a normal physiological change. It is typically white or clear and does not indicate any immediate problems unless it is accompanied by other symptoms such as itching, foul odor, or irritation.
Numbness or tingling in the fingers during pregnancy can be caused by pressure on nerves due to fluid retention or changes in the body's circulation. While it can be uncomfortable, it is not typically considered an urgent issue unless it is severe, persistent, or accompanied by other concerning symptoms.
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