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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Rationale:

A. "I will use an interpreter when providing client teaching.": An interpreter is useful for clients with language barriers. Expressive aphasia affects speech production, not comprehension, so an interpreter would not address the main communication challenge.

B. "I will use a communication board to assess the client's needs.": A communication board allows the client to point to words, pictures, or symbols to express thoughts and needs without relying on verbal speech. This is an effective method for facilitating communication with expressive aphasia.

C. "I will provide written instructions for the client in 8-point font.": Written instructions can help if reading skills are intact, but 8-point font is too small for easy readability, especially for clients who may also have vision changes. Larger, clear print is recommended.

D. "I will use indirect lighting in the client's room.": Lighting preferences may improve comfort, but they do not address the core communication difficulty caused by expressive aphasia. This intervention is unrelated to improving the client-nurse communication.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

Rationale for correct choices:

Obtain IV access: The client has hypotension (BP 90/50 mm Hg), tachycardia (HR 118/min), and significant anemia (Hgb 9.1 g/dL, Hct 27%), all of which suggest possible active gastrointestinal bleeding. Establishing IV access is a priority to allow rapid fluid resuscitation or blood product administration as needed.
Prepare for a blood transfusion: Given the positive hemoccult stool, anemia, and vital sign changes, the client may require a blood transfusion to restore hemodynamic stability and oxygen-carrying capacity. Preparing for transfusion ensures timely intervention in case of worsening blood loss.

Rationale for incorrect choices:

Call the surgical suite to notify that the client is arriving STAT: While the client is scheduled for endoscopy, immediate stabilization takes priority over notifying the surgical suite. The client’s hemodynamic status must be addressed first to prevent deterioration.
Recheck the client's oxygen saturation: The client’s oxygen saturation is 98% on room air, which is within normal limits. Rechecking is not immediately necessary and does not address the urgent need for stabilization.
Place the client in a supine position with feet elevated: Although elevating the feet can help improve perfusion temporarily, it does not treat the underlying anemia or hypotension and is less urgent than establishing IV access and preparing for transfusion.
Offer oral fluids: Oral intake is contraindicated in a client at risk for endoscopy and possible GI bleeding. Fluids could increase the risk of aspiration and do not address hemodynamic instability.
Administer PRN antacids: Antacids may provide minor symptom relief but do not treat active blood loss or stabilize the client before endoscopy.
Document vital signs: Documentation is important but secondary to immediate interventions that address the client’s hypotension and potential hemorrhage.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

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