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?

The correct answer is D. Remind the client to use the incentive spirometer.

Choice A rationale:

Observing the position of the suspended weight is beyond the scope of practice for assistive personnel (AP). This task requires assessment skills to ensure proper alignment and functioning of the traction system, which is the responsibility of the nurse.

Choice B rationale:

Checking the client’s pedal pulse on the right leg involves assessment and clinical judgment to evaluate perfusion and detect potential complications such as impaired circulation. This is not a task that can be delegated to AP.

Choice C rationale:

Asking the client to describe her pain requires assessment and interpretation of subjective data, which falls under the nurse's scope of practice. Pain assessment is a critical nursing function.

Choice D rationale:

Reminding the client to use the incentive spirometer is a non-assessment task that involves reinforcing previously taught instructions. This is appropriate to delegate to assistive personnel, as it does not require clinical judgment.

Choice A reason:

Administer epinephrine subcutaneously. This is not the necessary action to be taken. Epinephrine is used to treat severe allergic reactions (anaphylaxis). However, in this case, the client is experiencing a febrile non-haemolytic transfusion reaction, not an allergic reaction.

Choice B reason:

Place the blood bag in a biohazard bag before discarding. This is not the necessary action to be taken by the nurse. Proper disposal of biohazardous materials is essential, but in this situation, the nurse's priority is to address the client's condition and not the disposal of the blood bag

Choice C reason:

Documentation of the transfusion reaction is crucial for the client's medical history and for future reference. The nurse should record the client's signs and symptoms, the actions taken, and any other relevant information related to the reaction.

Choice D reason

Infuse 500 ml lactated Ringer's IV. This is not necessary action to be taken by the nurse because there is no indication for infusing lactated Ringer's solution in response to the transfusion reaction described. Treatment for febrile non-haemolytic transfusion reactions generally involves stopping the transfusion, administering antipyretics (like acetaminophen) if necessary, and providing supportive care as needed.