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
Applying suction while inserting the catheter is incorrect and can cause tissue damage and hypoxia. Suction should only be applied while withdrawing the catheter to prevent injury to the tracheal mucosa.
Choice B rationale
Applying intermittent suction for up to 30 seconds is excessive and can cause hypoxia and trauma to the trachea. The correct duration for intermittent suctioning is 10-15 seconds per pass to minimize these risks.
Choice C rationale
Preoxygenating the client prior to suctioning helps prevent hypoxia by ensuring the client has adequate oxygen reserves during the procedure. This is a standard practice to enhance patient safety during suctioning.
Choice D rationale
Instructing the client to swallow during catheter insertion is inappropriate and can lead to gagging or aspiration. The client should be relaxed and still during insertion to prevent complications.
Correct Answer is A
Explanation
Choice A rationale
"Let's talk about what you're thinking.”. This response encourages open communication and allows the nurse to address any concerns or confusion the client may have. It shows empathy and helps build a therapeutic relationship.
Choice B rationale
"Is this something you think you can do?" While this question assesses the client's confidence, it may not address underlying concerns that cause distraction. The focus should be on understanding the client's thoughts and feelings first.
Choice C rationale
"Are you feeling okay?" This question is more about physical well-being, which may not be the reason for the client's distraction. It's better to address emotional or cognitive concerns related to the teaching session.
Choice D rationale
"Do you need more time to absorb this information?" While offering more time can be helpful, it doesn't directly address the client's distraction. Engaging the client in a conversation about their thoughts can be more effective in understanding their needs.
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