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 D
Explanation
Choice A rationale
Measuring the bladder before the patient voids would not provide an accurate measurement of postvoid residual, which is the amount of urine left in the bladder after voiding.
Choice B rationale
The position of the head of the bed does not directly impact the measurement of postvoid residual. However, the patient should be in a comfortable position during the procedure.
Choice C rationale
Similar to Choice B, the position of the head of the bed does not directly impact the measurement of postvoid residual.
Choice D rationale
Measuring the bladder within 15 minutes after the patient voids allows for an accurate measurement of postvoid residual, which can help assess bladder function.
Correct Answer is ["24"]
Explanation
Step 1 is: To find out how many mL/hr the IV pump should be set to deliver, we need to set up a proportion with the prescribed units of heparin on one side and the available units of heparin on the other side. So, the calculation is: (1,200 units/hr ÷ 25,000 units) × 500 mL = 24 mL/hr.
Therefore, the IV pump should be set to deliver 24 mL/hr.
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