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 B,A,C,D,E
Explanation
Choice A rationale
Unlocking and removing the inner cannula is the first step. It allows access to the inner cannula for cleaning and ensures that the tracheostomy tube remains patent.
Choice B rationale
Pouring 2.54 cm (1 in) of 0.9% sodium chloride solution into the sterile basin provides the necessary solution for cleansing the inner cannula and stoma site, helping to maintain sterility and prevent infection.
Choice C rationale
Scrubbing the inside and outside of the inner cannula with a small brush ensures that any mucus or debris is removed, reducing the risk of infection and maintaining clear airways.
Choice D rationale
Wiping the inside of the inner cannula with a folded pipe cleaner helps to remove any remaining debris or solution, ensuring that the inner cannula is thoroughly cleaned.
Choice E rationale
Cleansing the stoma site with 0.9% sodium chloride solution helps to remove any mucus or debris from the site, maintaining hygiene and reducing the risk of infection.
Correct Answer is C
Explanation
Choice A rationale
Hyperactive bowel sounds indicate increased gastrointestinal activity, often associated with conditions like gastroenteritis or diarrhea. While it requires monitoring, it is not immediately concerning in the context of administering medications via a gastrostomy tube.
Choice B rationale
Yellowish-green stomach contents suggest the presence of bile, a normal finding in gastric aspirates. It indicates that the tube is correctly placed in the stomach, which is crucial before administering medications.
Choice C rationale
A pH of 6.5 for aspirated stomach contents suggests that the tube might be dislocated into the respiratory tract or intestines, as normal gastric pH ranges from 1.5 to 3.5. Reporting this finding is critical to avoid complications.
Choice D rationale
A residual volume of 90 mL is within the acceptable range for most clients with gastrostomy tubes. High residual volumes (usually over 200 mL) are more concerning and may require intervention.
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