The nurse is assessing the patient's output for the shift. What finding is most concerning?

A. Obtain daily urine specimens by opening the collection drainage system: Opening the drainage system increases the risk of introducing bacteria into the catheter, which can lead to infection.

B. Keep the urine collection bag below the level of the bladder at all times: Keeping the bag below the bladder prevents urine from back flowing into the bladder, which reduces the risk of infection.

C. Retract the foreskin to clean the catheter tubing and meatus outward, leaving the foreskin retracted: While the foreskin should be retracted for cleaning, it must always be returned to its normal position to prevent paraphimosis, a condition where the foreskin becomes trapped and restricts blood flow.

D. Change the indwelling catheter at least every one week: Routine catheter changes are not recommended unless there is an indication such as obstruction or infection. Unnecessary changes increase infection risk.

A. Providing a detailed SBAR report to the primary nurse: SBAR (Situation, Background, Assessment, Recommendation) is a standard communication tool used among healthcare professionals to ensure continuity of care. Since this report is given to the primary nurse who is part of the healthcare team, it does not violate confidentiality.

B. Collaborating with the patient care technician for hygiene care: Patient care technicians (PCTs) are part of the healthcare team, and sharing necessary patient information with them to ensure hygiene care does not breach confidentiality.

C. Discussing the client's medications with the clinical instructor: A clinical instructor is responsible for overseeing student learning and patient safety. As long as the discussion is conducted in an appropriate setting (e.g., away from unauthorized persons), it does not violate confidentiality.

D. Writing the client's initials on the student care plan: Even using initials instead of a full name can still be considered identifiable information if someone can link it to a specific patient. To maintain confidentiality, students should use de-identified data in their care plans.