A nurse is obtaining a sterile urine specimen from a client who has an indwelling urinary catheter. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
Wipe the sample port with an alcohol wipe and let the alcohol dry.
Clamp the catheter tubing distal to the sampling port for 15 min.
Attach a sterile needleless syringe to the sample port and aspirate the specimen
Document in the client's electronic medical record that the specimen was sent to the laboratory.
Empty the urine into a sterile container labeled with the client identifiers
The Correct Answer is B, A, C, E, D
Clamp the catheter tubing distal to the sampling port for 15 min. By clamping the tubing distal to the sampling port, it allows urine to accumulate in the tubing, ensuring that the urine specimen obtained is fresh and not from the stagnant urine that has been sitting in the tubing.
Wipe the sample port with an alcohol wipe and let the alcohol dry. Cleaning the sampling port with an alcohol wipe helps reduce the risk of introducing contaminants into the sample during collection, ensuring a more sterile procedure.
Attach a sterile needleless syringe to the sample port and aspirate the specimen. Using a sterile syringe prevents contamination and allows for the collection of a clean urine sample directly from the catheter tubing, maintaining the sterility of the specimen.
Empty the urine into a sterile container labeled with the client identifiers. Transferring the collected urine into a sterile container labeled with the client's identifiers ensures proper identification and handling of the specimen for laboratory analysis.
Document in the client's electronic medical record that the specimen was sent to the laboratory. Documenting in the client's medical record ensures that there is a clear record of the specimen collection, its handling, and its dispatch to the laboratory for analysis, maintaining proper documentation and continuity of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Keeping both arms below the level of the client's heart doesn't specifically address the prevention of lymphedema and might not be necessary for this purpose.
Choice B Reason:
Limiting range-of-motion exercises with the affected arm could potentially contribute to stiffness and reduced function, but appropriate and gradual range-of-motion exercises are generally recommended to prevent lymphedema.
Choice C Reason:
Using the client's left arm to obtain blood samples is correct. Lymphedema can occur due to the disruption of lymphatic vessels during surgery, leading to the accumulation of lymph fluid. To reduce the risk of lymphedema, medical procedures or blood draws should typically avoid using the affected arm. In this case, after a right radical mastectomy, using the left arm for blood samples can help protect the compromised lymphatic system in the right arm.
Choice D Reason:
Obtaining blood pressure readings using the client's right arm is not directly related to preventing lymphedema. However, excessive pressure or trauma to the affected arm should generally be avoided to reduce the risk of lymphedema.
Correct Answer is A
Explanation
Choice A Reason:
Replace the unit when the drainage chamber is full is correct. Regularly emptying the drainage chamber when it becomes full is essential to ensure the drainage system functions properly and continues to effectively remove fluids or air from the chest cavity.
Choice B Reason:
Clamp the tube for 30 min every 8 hr. is incorrect.
Clamping a chest tube without a specific medical order or indication can lead to complications such as a buildup of pressure within the chest cavity or potential damage to the lungs. It's generally not a routine action to clamp the tube without proper instruction.
Choice C Reason:
Pin the tubing to the client's bed sheets is incorrect. Pinning the tubing to the bed sheets can cause tension on the chest tube, leading to accidental dislodgment or obstruction. The tubing should be secured but not pinned to prevent inadvertent movement.
Choice D Reason:
Monitor for at least 150 mL of drainage every hour is incorrect. There isn't a standard or prescribed amount of drainage that should occur hourly. The nurse should monitor the drainage rate and characteristics but shouldn't expect a specific volume within a set timeframe. Monitoring for excessive or decreased drainage and changes in characteristics is crucial, but an hourly volume expectation isn't appropriate.
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