A nurse is reinforcing teaching with a client about intermittent catheterization to measure residual urine. Which of the following information should the nurse include in the teaching?

A) Coiling the tubing on the bed above the collection bag is incorrect because it can cause urine to flow back into the bladder, increasing the risk of infection and compromising the effectiveness of the drainage system. The tubing should be kept below the level of the bladder to ensure proper drainage.

B) Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which could lead to a urinary tract infection (UTI).

C) Securing the tubing with adhesive tape to the lower abdomen is correct because it helps prevent accidental pulling or tugging on the catheter, which could cause discomfort or dislodgement. Properly securing the tubing also helps maintain a continuous flow of urine and reduces the risk of infection.

D) Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe.

Choice A Reason:

Documenting the event in the client's progress notes is not the immediate action to take. While it's important to document significant events, the priority is to stop the unauthorized disclosure of the client's information and address the privacy breach.

Choice B Reason:

Informing the client of the APs' actions is not the initial step to take. The priority is to address the issue and stop the conversation to prevent further disclosure of confidential information. However, the client may need to be informed about the breach of privacy as part of the organization's protocol.

Choice C Reason:

Telling the APs to stop the conversation is correct. Overhearing discussions about a client's personal information by unauthorized personnel is a breach of patient privacy and confidentiality, which is a serious violation of healthcare ethics and regulations. Therefore, the nurse should address the situation immediately by telling the assistive personnel (APs) to stop the conversation. Here's why each option is appropriate or not:

Choice D Reason:

Submitting an incident report to the risk manager is an appropriate step to take but should not be the first action. The immediate concern is to address the situation and stop the unauthorized discussion. After that, the incident should be documented and reported according to the facility's policies and procedures.