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“I will keep the collecting bag below the level of the bladder at all times.” Keeping the bag lower than the bladder uses gravity to prevent the backflow (reflux) of contaminated urine into the bladder, which is a primary cause of infection.

“Intake of cranberry juice may help decrease the risk of infection.” Cranberry juice contains compounds that can prevent E. coli bacteria from adhering to the bladder wall. While it doesn't cure an infection, it is a common preventative measure for home care clients.

“I should use clean technique when emptying the collecting bag.” In a home setting, clean technique (medical asepsis) is the standard for emptying the bag, provided the drainage spigot does not touch the collection container or the floor.

Irrigation of the catheter with 30 mL of normal saline solution every 4 hours: Routine irrigation is not recommended because it breaks the closed system and significantly increases the risk of introducing bacteria into the bladder. Irrigation is only performed if there is an obstruction like blood clots or per a specific surgeon's order.

Disconnecting and reconnecting the drainage system quickly to obtain a urine specimen: You should never disconnect the catheter from the drainage tube to collect a specimen. Most modern catheters have a needleless sampling port on the tubing. Disconnecting the system creates a portal of entry for pathogens.

Telling the client that burning and irritation are normal, subsiding within a few days: While mild awareness of the catheter is common, persistent burning and irritation are not normal and can be signs of a UTI, urethral trauma, or a catheter that is improperly secured and pulling on the bladder neck.

Pouring warm water over the client’s fingers: This is a sensory stimuli technique. The sound and feel of running warm water can trigger the micturition reflex, helping the patient relax the urinary sphincter to initiate voiding.

Using a warm bedpan when the client feels the urge to void: A cold bedpan causes muscles to tense up (vasoconstriction and guarding). A warm bedpan promotes pelvic muscle relaxation, which is necessary to allow urine to pass.

Stroking the client’s leg or thigh: This is another form of tactile stimulation that can sometimes stimulate the nerves responsible for the voiding reflex in patients struggling with postoperative urinary retention.

The close proximity of the male genitalia to the rectum: While this is a major factor for female clients due to a short urethra and close proximity, it is less of a factor for males. The male urethra is longer, providing a greater distance for bacteria to travel to reach the bladder.

Decreased immunity: Being 80 years old and having diabetes mellitus does result in decreased immunity, making it harder for the body to fight an infection. However, decreased immunity is a predisposing factor, not the direct mechanical cause of the infection in this scenario.

A high urine glucose level: In diabetes, glucose in the urine (glycosuria) provides an excellent food source for bacteria to multiply. Like decreased immunity, this makes an infection more likely to thrive, but it is not the primary vehicle that introduces the bacteria.

Incontinence is to be expected in a woman her age: This is a common myth. While the risk of incontinence increases with age due to physiological changes, it is not a normal or inevitable part of aging. It should always be investigated as a treatable condition rather than dismissed as expected.

One of every 10 nursing home residents is incontinent: This statistic is significantly underestimated. Research suggests that over 50% (and some studies suggest up to 75%) of nursing home residents experience some form of urinary incontinence.

An indwelling catheter should be inserted as soon as possible: This is a last resort intervention. Indwelling catheters carry a high risk of infection (CAUTI) and tissue trauma. They should never be used for the convenience of staff or as a first-line treatment for an ambulatory, alert client.

Pharmacologic measures: While medications like anticholinergics can be used for urge incontinence, they are considered second-line treatments. In older adults, these drugs often cause significant side effects like confusion, dry mouth, and constipation.

Surgical intervention: Surgery is usually reserved for specific structural issues like a prolapsed bladder or severe stress incontinence after conservative treatments have failed. It is the most invasive option and carries the highest risk for an older adult.

Use of absorbent products: Absorbent products (pads or diapers) are a management strategy, not a treatment. While they keep the client dry in the short term, they do not help fix the bladder issue and can lead to skin breakdown if used as a substitute for actual care.

Pale yellow is the color of normal, dilute urine. Phenazopyridine is a potent dye that significantly alters the appearance of urine; it would not result in a normal appearance.

Green urine is less common and can be caused by certain medications (like amitriptyline or propofol), pseudomonas infections, or specific food dyes. It is not an expected side effect of phenazopyridine.

Brown or tea-colored urine is often associated with liver dysfunction, severe dehydration, or certain antibiotics like nitrofurantoin or metronidazole. While phenazopyridine can look very dark, its primary characteristic is the vibrant orange hue.

Assisting him in assuming his normal voiding position: This is a positive intervention. For most men, standing is the natural position for urination. Using gravity and familiar body mechanics helps relax the urethral sphincter and facilitates bladder emptying.

Pulling curtains around him to provide privacy: This is a standard nursing intervention that reduces stress. Privacy is essential for relaxation; a lack of privacy is more likely to cause shy bladder (paruresis) and worsen retention.

Offering the urinal on a regular schedule: This is a helpful, proactive nursing action. Regular timed voiding helps prevent the bladder from overstretching, which can weaken the detrusor muscle and worsen retention.

An adult older than 65 years: Involuntary urination in an older adult is referred to as urinary incontinence. This is typically related to physical issues like weakened pelvic floor muscles, prostate enlargement, or cognitive decline.

A 12-month-old child: Involuntary urination is a normal physiological state for a 1-year-old. At this age, the nervous system has not matured enough to control the external urethral sphincter. Therefore, it cannot be diagnosed as impaired elimination or enuresis; it is simply developmental.

A client with neurologic damage: This is known as a neurogenic bladder. While it results in impaired elimination, the cause is structural or traumatic damage to the nerves (like a spinal cord injury), not a delay in the natural maturational process of growing up.

The incontinence pattern: To evaluate if a plan is working, you must compare current data against the baseline. Knowing when, where, and how often the client is incontinent helps determine if the frequency has decreased or if the interventions like scheduled voiding are effective.

State of physical mobility: Functional incontinence is often caused by the inability to reach the toilet in time. If the plan includes mobility exercises or assistive devices, evaluating the client's current movement status is crucial to seeing if physical improvements are aiding continence.

Medications being taken: Many medications (diuretics, sedatives, or anticholinergics) can cause or worsen incontinence. Monitoring these is vital to see if pharmacological side effects are hindering the success of the nursing plan.

Slowly inflate with sterile saline: While balloons are inflated with liquid, sterile water is used, not saline. Saline can crystallize over time, causing the balloon to get stuck or the valve to malfunction. Furthermore, inflation should only happen after correct placement is confirmed.

Secure to bedsheets: The drainage tubing should never be secured to the bedsheets because if the client moves, the catheter could be pulled or tensioned. The catheter should be secured to the client's thigh or abdomen to prevent urethral trauma.

Advance until urine flows, then insert 1/4 inch more: This is a technique often used for female clients. For males, seeing urine flow only confirms the tip is in the bladder; however, since the balloon is further down the shaft, the catheter must be advanced much further to the bifurcation before inflation.

Remove and start over with a new kit: While you do need a new catheter, you don't necessarily need an entirely new sterile kit if your sterile field is still intact. More importantly, removing the misplaced catheter first loses your visual marker.

Pull back and reinsert at a different angle: Once the catheter has entered the vagina, it is considered contaminated. You cannot pull it back and put it into the sterile urethra; doing so would introduce vaginal bacteria into the urinary tract, significantly increasing the risk of infection.

Ask to bear down and insert farther: While bearing down can help relax the external sphincter, if the catheter is already in the vagina, pushing it farther will not produce urine and does not solve the placement error.