A nurse is collecting a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter.
Which of the following actions should the nurse take?
Place the specimen in a clean specimen cup.
Remove 45 mL of urine from the catheter with a syringe.
Clamp the catheter tubing below the needleless port.
Clamp the catheter tubing for 60 min.
The Correct Answer is C
Choice A rationale
Placing the specimen in a clean specimen cup is not appropriate for a urine culture and sensitivity test. A sterile specimen cup is required to avoid contamination and ensure accurate results.
Choice B rationale
Removing 45 mL of urine from the catheter with a syringe is incorrect. Only 5-10 mL of urine is needed for a culture and sensitivity test, and excessive removal can lead to inaccurate test results or sample contamination.
Choice C rationale
Clamping the catheter tubing below the needleless port is the correct action. This allows urine to accumulate in the tubing, providing a fresh and uncontaminated sample for the culture and sensitivity test.
Choice D rationale
Clamping the catheter tubing for 60 minutes is too long and can cause urine stasis, increasing the risk of catheter-associated urinary tract infections. The tubing should be clamped only for a short duration to collect an adequate sample. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Suggesting that the family member contact a grief counselor may be helpful, but it does not address their immediate need to help. Involving the family member in care can provide emotional support and a sense of purpose.
Choice B rationale
Describing a personal experience with the death of a family member may offer empathy but can shift the focus away from the client's needs. It is essential to keep the conversation centered on the family member's desire to help.
Choice C rationale
Including the family member in providing care for the client is an appropriate action. It allows them to participate actively, provides emotional support, and can be comforting for both the client and the family member.
Choice D rationale
Asking if the family member has had prior experience with the death of a family member may be relevant but does not directly address their desire to help. It is more effective to involve them in the care process immediately. .
Correct Answer is A
Explanation
Choice A rationale
Asking if there are any problems taking care of feet directly assesses the client’s ability to perform foot self-hygiene. It opens up discussion about specific difficulties the client may face, such as flexibility, vision, or dexterity issues.
Choice B rationale
Asking if the client goes barefoot at home is related to foot safety but does not directly assess their ability to perform foot self-hygiene. It's important for preventing injuries and infections, especially in clients with diabetes.
Choice C rationale
Inquiring about foot swelling helps identify potential complications related to diabetes but does not address the client's ability to perform foot self-care.
Choice D rationale
Asking about problems with ingrown toenails is specific to a common issue in diabetic foot care but does not provide a comprehensive assessment of the client’s ability to maintain foot hygiene.
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