A nurse is planning care for a client who has a history of urinary tract infections (UTIs) and requires placement of an indwelling urinary catheter.
Which of the following actions should the nurse take to help minimize the client's risk for acquiring a UTI?
Loop the tubing so that it is lower than the collection bag.
Keep the urinary bag at bladder level when ambulating.
Obtain urinary samples by disconnecting the tubing connections.
Secure the catheter to the client's thigh.
The Correct Answer is B
Choice A rationale:
Looping the tubing so that it is lower than the collection bag creates a dependent loop where urine can pool, increasing the risk of UTI. This practice should be avoided as it can lead to bacterial contamination and subsequent infections.
Choice B rationale:
Keeping the urinary bag at bladder level when ambulating helps maintain a continuous flow of urine into the collection bag without creating dependent loops. This practice minimizes the risk of bacterial contamination and reduces the chances of acquiring a UTI.
Choice C rationale:
Obtaining urinary samples by disconnecting the tubing connections is not recommended. This procedure can introduce bacteria into the urinary system, increasing the risk of UTI. Sterile techniques, such as using a catheter port for sampling, should be followed to minimize the risk of infection.
Choice D rationale:
Securing the catheter to the client's thigh is essential to prevent tension and pulling on the catheter, which can cause trauma to the urethra. However, securing the catheter alone does not minimize the risk of UTI. Proper hygiene, closed drainage system, and maintaining a continuous flow of urine into the collection bag are key factors in preventing UTIs in clients with indwelling urinary catheters.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["255"]
Explanation
Step 1: Calculate half the total volume. The total volume is 4,080 mL. So, half the total volume is 4,080 mL ÷ 2 = 2,040 mL.
Step 2: Calculate the rate to administer half the total volume in the first 8 hours. So, the rate is 2,040 mL ÷ 8 hr = 255 mL/hr.
Therefore, the nurse should set the IV infusion pump to deliver 255 mL/hr to administer half the total volume in the first 8 hr.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: “What are the voices telling you?” This is the priority response because it directly addresses the client’s immediate concern. The nurse is acknowledging the client’s experience and seeking to understand more about it. This can help the nurse assess the potential for harm to the client or others, as the voices may be instructing the client to engage in dangerous behaviors.
Choice B rationale: “Have you taken your medication today?” While medication adherence is important in managing schizophrenia, this response does not address the client’s immediate concern about hearing voices. It may also come across as dismissive of the client’s experience.
Choice C rationale: “I realize the voices are real to you, but I don’t hear anything.” This response validates the client’s experience, but it does not gather further information about what the voices are saying, which is crucial for assessing safety.
Choice D rationale: “How long have you been hearing the voices?” While this question is relevant for understanding the client’s history and the progression of their illness, it is not the priority response. The immediate concern should be what the voices are saying to assess for potential harm.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.