A nurse is evaluating a nursing assistive personnel’s (AP) care for a patient with an indwelling catheter. Which action by the AP will cause the nurse to intervene?

Emptying the drainage bag when half full.

Placing the drainage bag on the side rail of the patient’s bed.

Kinking the catheter tubing to obtain a urine specimen.

Securing the catheter tubing to the patient’s thigh.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Emptying the drainage bag when half full is a correct action by the AP4. It is important to empty the drainage bag regularly to prevent infection and maintain accurate intake and output records.

Choice B rationale

Placing the drainage bag on the side rail of the patient’s bed is an incorrect action by the AP4. The drainage bag should be placed below the level of the bladder to prevent backflow of urine, which can lead to infection.

Choice C rationale

Kinking the catheter tubing to obtain a urine specimen is an incorrect action by the AP4. This can cause discomfort to the patient and potentially damage the catheter.

Choice D rationale

Securing the catheter tubing to the patient’s thigh is a correct action by the AP4. This helps to prevent pulling on the catheter, which can cause discomfort and potential damage to the urethra.

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Correct Answer is C

Explanation

If the nurse suspects the catheter is not in the urethra, they should leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter.

A. Use soap to clean the patient’s skin. B. Apply a barrier cream to the patient’s skin. C. Avoid applying friction when drying the patient’s skin. D. Use warm water to clean the patient’s skin.

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

Explanation

Choice A rationale

Using soap to clean the patient’s skin is not the best practice. Soap can dry out and irritate the skin, especially in patients with urinary incontinence. It can disrupt the skin’s natural pH balance and make it more susceptible to damage.

Choice B rationale

Applying a barrier cream to the patient’s skin is a recommended practice. Barrier creams provide a protective layer on the skin that can help prevent irritation from urine. They can also help to keep the skin moisturized, which is important for maintaining skin integrity.

Choice C rationale

Avoiding friction when drying the patient’s skin is crucial. Friction can cause further damage to the skin, especially in areas that are already irritated or broken down due to incontinence. It’s recommended to gently pat the skin dry rather than rubbing it.

Choice D rationale

Using warm water to clean the patient’s skin is a good practice. Warm water is less irritating to the skin than hot water and can help to cleanse the area without causing additional discomfort or damage.

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A nurse is evaluating a nursing assistive personnel’s (AP) care for a patient with an indwelling catheter. Which action by the AP will cause the nurse to intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is inserting a catheter into a female patient. When the nurse inserts the catheter, no urine is obtained. The nurse suspects the catheter is not in the urethra. What should the nurse do?

Correct Answer is C

Explanation

A nurse is providing skin care for a patient with urinary incontinence. What actions should the nurse take?

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

Explanation

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