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 D
Explanation
This scenario requires applying knowledge of burn pathophysiology, specifically the emergent phase and fluid resuscitation. Understanding clinical indicators of hypovolemia, such as heart rate and urine output, is essential to recognize inadequate perfusion and potential hypovolemic shock.
Choice A rationale
Normal adult respirations range from 12 to 20 breaths per minute. A pulse of 60 bpm is at the low end of the normal range of 60 to 100 bpm, which does not suggest hypovolemic shock.
Choice B rationale
A temperature of 98.4 F is within the normal range of 97 F to 99 F. While a pulse of 106 bpm is slightly tachycardic, it is not a definitive indicator of critical fluid deficit.
Choice C rationale
A blood pressure of 92/60 mm Hg is borderline low, but a pulse of 100 bpm is at the upper limit of normal. These findings are less concerning than those indicating direct organ hypoperfusion.
Choice D rationale
Tachycardia of 130 bpm and urine output below 30 mL/hr signify inadequate fluid resuscitation. Normal urine output is at least 0.5 mL/kg/hr, or 30 mL/hr, indicating decreased renal perfusion and significant hypovolemia in burn patients.
Correct Answer is B
Explanation
Evaluating neurological progression in traumatic brain injury involves applying the Glasgow Coma Scale and understanding brainstem function. Recognising the shift between abnormal posturing patterns is critical for identifying descending levels of brain injury and worsening central nervous system herniation.
Choice A rationale
Improved motor response, such as moving from abnormal posturing to localizing pain or following commands, indicates neurological recovery. This reflects better integration of the motor cortex and brainstem, suggesting that the initial injury or pressure is resolving.
Choice B rationale
Decorticate posturing involves damage to the corticospinal tract, while decerebrate posturing indicates more severe damage lower in the midbrain or brainstem. Progressing from decorticate to decerebrate signals significant neurological deterioration and potential brainstem herniation.
Choice C rationale
Decreased agitation can sometimes be a positive sign of recovery or a neutral sign of sedation. It does not specifically indicate worsening neurological status unless accompanied by a significant drop in the overall level of consciousness.
Choice D rationale
Increased responsiveness to external stimuli is a hallmark of neurological improvement. It suggests that the ascending reticular activating system and cerebral cortex are becoming more functional and integrated, which is the opposite of a worsening clinical state.
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