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
Explanation
Timolol is a beta-blocker medication that is commonly prescribed for the treatment of glaucoma. It works by reducing the production of aqueous humor in the eye, thereby decreasing intraocular pressure. However, timolol can also be systemically absorbed, which may lead to cardiovascular side effects.
Checking the heart rate while taking timolol is important because beta-blockers can potentially lower heart rate and blood pressure. It is essential to monitor for any changes in heart rate or any other cardiovascular symptoms while using timolol eye drops.
Correct Answer is C
Explanation
An incident report is a formal document used to report any unexpected or adverse events that occur during patient care. In this case, the administration of an incorrect dosage is an incident that should be documented in the incident report. The incident report serves as a record of the event and helps to ensure that appropriate follow-up actions are taken to prevent similar incidents in the future. It is important to note that an incident report is not part of the client's permanent medical record and is kept separate from other documentation.
The provider's progress notes, nursing care plan, and controlled substance inventory record are not appropriate locations to document this specific incident. The provider's progress notes are typically used to document the client's medical history, examination findings, treatment plans, and progress. The nursing care plan is a document that outlines the client's nursing diagnoses, goals, and interventions. The controlled substance inventory record is used to track and document the dispensing and administration of controlled substances, but it does not typically include incident reporting.
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