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.

Clamp the catheter tubing below the needleless port.

Clamp the catheter tubing for 60 min.

Remove 45 mL of urine from the catheter with a syringe.

Answer and Explanation

The Correct Answer is B

A) Place the specimen in a clean specimen cup. - Urine collected from an indwelling urinary catheter should be obtained using a sterile technique, not placed directly into a clean specimen cup.
B) Clamping the catheter tubing for 10–30 minutes before collecting the sample allows fresh urine to accumulate in the tubing, ensuring a more accurate culture result. The urine should be collected from the designated port using aseptic technique, not from the catheter bag, as stagnant urine may contain contaminants.

C) Clamp the catheter tubing for 60 min. - Clamping the tubing for an extended period can cause urinary retention and discomfort for the client. It is not appropriate for collecting a urine specimen.
D) Only 3–5 mL of urine is needed for a culture. The nurse should collect the appropriate small amount to avoid unnecessary removal of urine.

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Body System	Findings
Neurological	Alert and oriented to person, place, and time; deep tendon reflexes 4+
Musculoskeletal	Generalized weakness with equal bilateral muscle strength and mild leg cramping
Respiratory	: Lungs clear
Cardiovascular	: Heart rate irregular, Heart rate 95/min
Gastrointestinal	Bowel sounds hyperactive x 4 quadrants

Correct Answer is ["A","B","C","D"]

Explanation

An irregular heart rhythm could indicate potential cardiovascular issues. Additionally, deep tendon reflexes graded at 4+ suggest hyperreflexia, which may be associated with neurological disorders and should be investigated further.

Hyperactive bowel sounds in all four quadrants could indicate gastrointestinal hypermotility, which might require prompt assessment to determine the underlying cause.

Generalized weakness and mild leg cramping also require follow-up to determine the cause.

A. Stand on the client's stronger side when moving the client into the chair. B. Flex hips and knees when assisting the client to a standing position. C. Raise the bed to waist level before moving the client. D. Pivot on the foot farthest from the bed when assisting the client into the chair.

Correct Answer is B

Explanation

A. The nurse should stand on the client’s weaker side (left side) to provide support and stability during the transfer. Standing on the stronger side offers less assistance and increases the risk of falls.
B. When assisting a client with left-sided weakness to transfer from bed to chair, the nurse should use proper body mechanics to protect both the client and self.Flexing the hips and knees allows the nurse to use the leg muscles (strongest muscles) rather than the back, reducing risk of injury. This position also provides stability and balance, allowing controlled movement as the client stands.
C. Raise the bed to waist level before moving the client- Adjusting the bed height can facilitate the transfer process, but it is not directly related to the client's left-sided weakness.
D. Pivot on the foot farthest from the bed when assisting the client into the chair- Pivoting on the foot farthest from the bed allows for a smooth and controlled transfer motion but does not address the client's left-sided weakness specifically.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is assisting in the transfer of a client who has left-sided weakness from a bed to a chair. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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