A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection?
Clamp the catheter distal to the injection port.
Drain the specimen from the drainage bag.
Collect 2 mL of urine for each specimen.
Obtain the urinalysis specimen before the culture specimen.
The Correct Answer is A
Rationale:
A. Clamp the catheter distal to the injection port: Clamping the catheter allows urine to accumulate in the tubing, ensuring a fresh specimen can be obtained from the sampling port rather than from stagnant urine in the drainage bag, which could be contaminated.
B. Drain the specimen from the drainage bag: Urine in the drainage bag may be old and contaminated, which can lead to inaccurate culture results. Specimens should be collected aseptically from the catheter sampling port.
C. Collect 2 mL of urine for each specimen: For accurate urinalysis and culture, a larger volume typically 3–10 mL for culture and 10–15 mL for routine urinalysis is recommended to ensure enough specimen for testing and repeat analysis if needed.
D. Obtain the urinalysis specimen before the culture specimen: Culture specimens should be collected first to prevent contamination. Performing urinalysis first can alter the bacterial composition of the sample and compromise culture accuracy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. "Your baby needs an IV because she is breathing slower than normal.": Severe dehydration is more likely to cause tachypnea rather than slower breathing, as the body attempts to compensate for metabolic acidosis.
B. "Your baby needs an IV because her heart rate is decreased.": Severe dehydration in infants usually results in tachycardia due to hypovolemia. A decreased heart rate may indicate impending cardiovascular collapse, which is a late and severe sign.
C. "Your baby needs an IV because her fontanels are bulging.": Bulging fontanels suggest increased intracranial pressure, not dehydration. Dehydration typically causes sunken fontanels due to decreased fluid volume.
D. "Your baby needs an IV because she is not producing tears.": Absence of tears during crying is a classic sign of significant dehydration in infants. This indicates reduced fluid volume and supports the need for IV therapy to restore hydration.
Correct Answer is D
Explanation
A. Raise the side rails up when the client is in bed: Full side rails can increase the risk of entrapment and injury for clients with dementia. They are not recommended as a routine safety measure unless individually assessed and ordered.
B. Place the bedside table at the foot of the bed: Placing furniture at the foot of the bed can create obstacles and increase the risk of trips and falls. The environment should be arranged to allow safe, unobstructed mobility.
C. Keep the television on during the night: Continuous noise, such as a TV, can cause agitation or confusion in clients with dementia, increasing the risk of disorientation and injury. Quiet, calming environments are preferred.
D. Assist the client to the toilet frequently: Clients with dementia are at increased risk for falls due to urgency, confusion, or impaired mobility. Frequent toileting assistance reduces the risk of incontinence-related hazards and falls, promoting safety and dignity.
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