A nurse manager is developing a protocol to reduce the incidence of UTIs in clients who have an indwelling urinary catheter. Which of the following interventions should the nurse include in the protocol?

Cleanse the periurethral area with antiseptic cleaning solutions.

Perform routine catheter irrigation every 8 hrs.

Limit indwelling urinary catheter usage to 4 days.

Maintain a closed system, ensuring connections are sealed securely.

Answer and Explanation

The Correct Answer is D

A. While cleansing the periurethral area is important, antiseptic cleaning solutions may not be necessary and could lead to irritation. Standard soap and water are often sufficient.

B. Routine catheter irrigation is not recommended and can increase the risk of infection. Catheters should be managed without unnecessary interventions.

C. Limiting indwelling urinary catheter usage is a good practice, but the protocol should focus on maintaining the catheter system rather than a specific time frame for removal.

D. Maintaining a closed system, ensuring connections are sealed securely, is critical in preventing urinary tract infections (UTIs) as it minimizes the risk of pathogens entering the urinary tract.

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Correct Answer is A

Explanation

A. Measuring the client's vital signs is the first step to assess the client's current physical status and determine if any physiological issues are contributing to confusion and agitation.

B. Offering reassurance to the family is supportive but does not address the immediate needs of the confused and agitated client.

C. Reorienting the client is helpful but should occur after ensuring that there are no underlying medical issues indicated by vital sign changes.

D. Medicating the client with alprazolam may be necessary if agitation is severe, but it should not be the first action taken before assessing the client's vital signs.

A. Explain the risks of the procedure to the client. B. Notify the provider about the client's concerns. C. Check to see if the medical record indicates the provider explained the procedure to the client. D. Convey the client's request to the nurse who witnessed the consent.

Correct Answer is B

Explanation

A. It is not within the nurse's scope of practice to explain the specific risks of a procedure; this responsibility lies with the provider who is performing the procedure.

B. If the client expresses concerns about the risks of the procedure, the nurse should notify the provider. This ensures that the provider can give detailed information to the client regarding the risks and benefits.

C. While checking the medical record may show whether the provider explained the procedure, it does not address the client's immediate concerns. The provider should still be notified.

D. It is not appropriate to pass the responsibility to the nurse who witnessed the consent; instead, the nurse should directly involve the provider in addressing the client's concerns.

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A nurse manager is developing a protocol to reduce the incidence of UTIs in clients who have an indwelling urinary catheter. Which of the following interventions should the nurse include in the protocol?

Nursing Test Bank

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