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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Donning sterile gloves before inserting the indwelling urinary catheter is a critical step to prevent infection. The urinary tract is normally sterile, and using sterile gloves helps maintain this sterility during the procedure.
Choice B rationale
Applying an oil-based lubricant to the indwelling urinary catheter is not recommended. Oil- based lubricants can damage latex catheters and increase the risk of infection. A water-soluble lubricant is typically used.
Choice C rationale
Using one cotton swab to clean the client’s genitalia is not sufficient. Proper cleaning and disinfection of the area are crucial to prevent introducing bacteria into the urinary tract during catheter insertion.
Choice D rationale
Testing the balloon on the indwelling urinary catheter before insertion is not typically done. The balloon is usually inflated with sterile water once the catheter is in place to ensure that it remains in the bladder.
Correct Answer is B
Explanation
Choice A rationale
0.9% sodium chloride, also known as normal saline, is an isotonic solution that is commonly used for hydration and to replace lost fluids. However, it does not provide any calories or nutrients, which are necessary for patients receiving TPN1.
Choice B rationale
Dextrose 10% in water (D10W) is the recommended solution to administer until the next TPN solution is available. This is a hypertonic fluid that provides dextrose to the patient, helping to maintain their blood glucose levels and reducing the risk of hypoglycemia.
Choice C rationale
3% sodium chloride is a hypertonic saline solution that is typically used to treat patients with severe hyponatremia (low sodium levels). It is not suitable as a replacement for TPN as it does not provide the necessary nutrients and can lead to hypernatremia (high sodium levels) if used inappropriately.
Choice D rationale
Lactated Ringer’s solution is an isotonic solution that is commonly used for fluid resuscitation in patients with significant fluid loss. While it does contain multiple electrolytes that mimic those found in plasma, it does not provide any calories or nutrients, making it unsuitable as a replacement for TPN1.
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