Which is the most appropriate action when obtaining a sterile urine specimen from an indwelling urinary catheter?
Swab the collection port of the catheter with an antiseptic swab. Insert a sterile needle and aspirate 3 to 5 mL of urine into the syringe.
Immediately clamp the catheter tubing.
Return one hour later and empty 3 to 5 mL of urine from the drainage bag into a sterile specimen container.
Flush the catheter with 10 mL of sterile water.
The Correct Answer is A
Insert a sterile needle and aspirate 3 to 5 mL of urine into the syringe. This is the best technique for obtaining a sterile urine specimen from an indwelling urinary catheter because it ensures that microorganisms in the specimen are from the urine, and not the result of contamination.
Choice B is wrong because it does not use sterile technique and it does not collect fresh urine. The urine in the drainage bag may have been sitting there for a long time and may not reflect the current condition of the patient’s urinary tract.
Choice C is wrong because it does not use sterile technique and it flushes the catheter with sterile water, which may dilute the urine and alter its composition.
Choice D is wrong because it does not use sterile technique and it collects urine from the drainage bag, which may be contaminated or stale.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should obtain a sputum culture specimen before administering any antibiotics to the client with bacterial pneumonia.
This is because the sputum culture can help identify the causative organism and the appropriate antibiotic therapy.
Administering antibiotics before obtaining the sputum culture can alter the results and lead to ineffective treatment.
Choice B is wrong because azithromycin is an antibiotic that should be given after obtaining the sputum culture.
Choice C is wrong because coughing and deep breathing are important interventions to promote airway clearance and gas exchange, but they are not the priority actions for this client.
Choice D is wrong because offering clear liquids can help prevent dehydration and thin secretions, but they are not the most urgent action for this client.
Normal ranges for blood urea nitrogen (BUN) are 7 to 20 mg/dL and for creatinine are 0.6 to
1.2 mg/dL.
Elevated levels of these substances can indicate renal impairment, which can be a complication of bacterial pneumonia.
The nurse should monitor these levels and report any abnormalities to the health care provider.
Correct Answer is ["A","B","C","D"]
Explanation
The correct answers are Choices A, B, C, and D.Choice A rationale:Inspection of lips and mucous membranes is a vital assessment technique for hydration status. Dryness or cracking of the lips and mucous membranes can indicate dehydration, as these areas are often affected by fluid loss. Observing these features helps healthcare providers assess the client's hydration level effectively.Choice B rationale:Pinching the skin on the back of the hand tests skin turgor, which is a reliable indicator of hydration status. If the skin does not return to its normal position quickly after being pinched, it suggests decreased skin elasticity due to dehydration. This method provides a quick visual and tactile assessment of fluid levels in the body.Choice C rationale:Measuring pulse and blood pressure is essential in evaluating hydration status. Changes in blood pressure (especially orthostatic hypotension) and pulse rate can indicate fluid volume changes in the body. An increased heart rate may suggest dehydration, while low blood pressure can indicate significant fluid loss.Choice D rationale:Obtaining the client's daily weight is a crucial method for monitoring hydration status. Weight fluctuations can provide insight into fluid retention or loss over time. A sudden decrease in weight may indicate dehydration, while an increase could suggest fluid overload or retention issues.Choice E rationale:Palpating scalp and hair distribution is not a common or effective method for assessing hydration status. While scalp condition may reflect overall health, it does not provide direct information about hydration levels compared to other methods listed.
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