A nurse is caring for a client who has an indwelling urinary catheter.
Which of the following actions should the nurse take to prevent infection?
Irrigate the catheter once each shift.
Clean the perineal area with an antiseptic solution daily.
Check the catheter tubing for kinks or twisting.
Replace the catheter every 3 days.
The Correct Answer is C
The management of indwelling urinary catheters requires strict adherence to evidence-based practices to prevent catheter-associated urinary tract infections. This scenario involves applying knowledge of aseptic technique, mechanical drainage patency, and the prevention of bacterial colonization within the urinary system.
Choice A rationale
Regular irrigation increases the risk of introducing pathogens into the sterile urinary tract by breaking the closed drainage system. Irrigation is only indicated for obstructions, such as blood clots, to maintain necessary catheter patency.
Choice B rationale
Daily perineal care should be performed with soap and water rather than antiseptic solutions. Antiseptics can irritate the urethral meatus and disrupt normal flora, potentially increasing the risk of bacterial overgrowth and subsequent infection.
Choice C rationale
Maintaining a prompt and unobstructed flow of urine is vital. Kinks or twists cause urine stasis, which allows bacteria to migrate upward into the bladder, significantly increasing the risk of developing a urinary tract infection.
Choice D rationale
Catheters should only be replaced based on clinical indications, such as obstruction or infection, not on a fixed schedule. Frequent, unnecessary changes increase the risk of urethral trauma and the introduction of exogenous microorganisms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Postoperative monitoring requires identifying deviations from expected healing milestones. Knowledge of surgical site infections and normal physiological parameters is necessary to distinguish between typical postoperative recovery and complications like dehiscence or sepsis that require immediate medical intervention.
Choice A rationale
A respiratory rate of 18/min is within the normal adult range of 12 to 20 breaths per minute. This indicates adequate ventilation and gas exchange following abdominal surgery, suggesting no immediate respiratory distress or pulmonary complications.
Choice B rationale
Yellow-green drainage indicates purulent exudate, suggesting a surgical site infection. This is an abnormal finding 48 hours postoperatively. Normal wound healing should show serosanguinous drainage. Any sign of infection necessitates prompt notification of the healthcare provider.
Choice C rationale
Straw-colored urine is a normal finding indicating adequate hydration and renal perfusion. Standard urinary output should exceed 30 mL/hr. Clear or straw-colored urine suggests that the kidneys are filtering waste products appropriately without hematuria.
Choice D rationale
A blood pressure of 102/66 mm Hg is slightly low but often acceptable postoperatively if the client is asymptomatic. The mean arterial pressure is ≥ 65 mm Hg, which is sufficient for vital organ perfusion and tissue oxygenation.
Correct Answer is D
Explanation
This case focuses on managing urolithiasis with signs of potential urinary obstruction. Knowledge of the nursing process, prioritization of physiological needs, and the distinction between pain management and critical organ perfusion/output is necessary to determine the first action.
Choice A rationale
Straining urine is important for stone analysis but is not the immediate priority for a client who hasn't voided in 6 hours. Assessment of the underlying cause of urinary retention must occur before focusing on stone recovery procedures.
Choice B rationale
Encouraging fluids helps flush stones but may exacerbate pain or vomiting if a total obstruction is present. The client's lack of output for 6 hours requires an assessment of bladder status before increasing fluid load significantly.
Choice C rationale
Pain management is essential for urolithiasis, but the lack of urinary output is a physiological priority. Assessing for bladder distention or obstruction ensures the kidneys are not sustaining damage from hydronephrosis before focusing solely on symptomatic relief.
Choice D rationale
Assessing for bladder distention is the priority to determine if the client is experiencing urinary retention due to obstruction. Identifying whether urine is being produced but trapped in the bladder is critical for preventing renal injury and hydronephrosis..
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