A nurse is caring for a client who has an indwelling urinary catheter.
The nurse notes that sediment is present in the urine.
Which of the following actions should the nurse take to obtain a sterile urine specimen?
Unclamp the collection port below the bag.
Obtain the specimen from the retention port.
Disconnect the catheter from the collection tubing.
Use the balloon port to obtain the sterile specimen.
The Correct Answer is B
Obtain the specimen from the retention port. This is because the retention port is a sterile site that can be accessed by a syringe to aspirate urine without contaminating the specimen or the closed drainage system. The retention port should be cleaned with an alcohol swab before inserting the syringe. The specimen should be transferred to a sterile container and labeled appropriately.
Choice A is wrong because unclamping the collection port below the bag would allow urine to flow out of the bag, which is not sterile and may contain bacteria or sediment. Choice C is wrong because disconnecting the catheter from the collection tubing would break the closed drainage system and increase the risk of infection. Choice D is wrong because using the balloon port to obtain the sterile specimen would deflate the balloon that holds the catheter in place and cause trauma to the bladder wall.
Normal ranges for urine characteristics vary depending on the type of analysis, but some general parameters are:
- Color: pale yellow to amber
- Clarity: clear or slightly cloudy
- Odor: faint aromatic
- pH: 4.5 to 8.0
- Specific gravity: 1.005 to 1.030
- Protein: <150 mg/24 hr
- Glucose: negative
- Ketones: negative
- Blood: negative
- Nitrites: negative
- Leukocyte esterase: negative
- Bacteria: <10,000 CFU/mL
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is A. I can lift objects that are less than 10 pounds.
Here's a breakdown of why the other options are incorrect:
- B. I can resume activities, such as sewing. - Sewing requires fine motor skills and close eye work, which can increase intraocular pressure and potentially worsen the detached retina.
- C. I can go jogging after 2 weeks. - Strenuous activities like jogging can increase blood pressure and strain the eye, potentially leading to another retinal detachment.
- D. I should bend at the waist when putting on my shoes. - Bending at the waist increases intraocular pressure and can strain the eye. It's recommended to sit down or use a stool to put on shoes.
Correct Answer is A
Explanation
Choice A reason:
"You might experience altered taste sensations" is the correct statement. When providing teaching to a client about to undergo external radiation therapy for cancer, the nurse should include information about potential side effects and what to expect during the treatment. One common side effect of radiation therapy, especially when the treatment is focused on or near the head and neck region, is altered taste sensations. Radiation can affect the taste buds and lead to changes in how foods taste.
Choice B reason:
"Use rubbing alcohol to remove the ink markings. “The statement is incorrect. The ink markings made on the client's skin are used as reference points for the radiation therapy treatment. It is essential not to remove these markings, as they are crucial for accurate positioning during each treatment session. The nurse should instruct the client not to tamper with the markings, and the radiation therapy team will remove them when they are no longer needed.
Choice C reason:
"Wear a binder over the radiation site." The statement is incorrect. Wearing a binder over the radiation site is not a standard practice during external radiation therapy. The client should be instructed to follow the specific guidelines provided by the radiation therapy team regarding clothing and positioning during treatments. The use of binders or other tight clothing over the treatment area may not be recommended, as it can cause discomfort or interfere with the delivery of radiation.
Choice D reason
"Wash your skin thoroughly with a washcloth after each treatment." Is incorrect statement. During radiation therapy, the skin in the treatment area can become sensitive. It is essential for the client to follow the specific instructions provided by the radiation therapy team regarding skin care. Generally, the client should avoid using harsh soaps or scrubbing the skin vigorously. Instead, they should gently cleanse the area with a mild soap or as directed by their healthcare providers.
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