A nurse is caring for a client who had an indwelling urinary catheter inserted 3 days ago. Which of the following actions should the nurse take?

Obtain urine from the drainage bag if a urinary specimen is required.

Use a catheter securing device to hold the catheter in place.

Position the drainage bag higher than the client's bladder.

Change the catheter bag every 3 days and as needed.

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Obtaining urine from the drainage bag if a urinary specimen is required is incorrect.

While obtaining urine from the drainage bag might seem practical for specimen collection, it's not the recommended method due to potential contamination of the specimen. A sterile sampling port or aspirating urine from the catheter tubing is a more appropriate technique.

Choice B Reason:

Using a catheter securing device to hold the catheter in place is correct. Securing the catheter with a proper securing device helps prevent unnecessary movement or tension on the catheter, reducing the risk of trauma to the urinary tract and ensuring stability for the catheter.

Choice C Reason:

Positioning the drainage bag higher than the client's bladder is incorrect. Positioning the drainage bag higher than the bladder can lead to backflow or reflux of urine, increasing the risk of urinary tract infections. The drainage bag should be placed below the level of the bladder to facilitate proper drainage.

Choice D Reason:

Changing the catheter bag every 3 days and as needed is incorrect. Routine changing of catheter bags every three days without clinical indication for changing can increase the risk of introducing infection. Catheter bags are changed based on clinical indications or when they are soiled or damaged, not on a fixed time schedule.

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Correct Answer is C

Explanation

Choice A Reason:

"I can't change my mind about the care I will receive once I sign my living will." Is incorrect.

This statement suggests a misconception that signing a living will locks in a permanent decision, whereas advance directives can usually be updated or modified as long as the individual is competent to do so.

Choice B Reason:

"If I want life support, I'll need to sign a separate consent form first." Is incorrect. While the concept of a consent form for specific treatments is relevant, it might not fully reflect the broader scope of advance directives, which encompass a range of healthcare preferences beyond just life support.

Choice C Reason:

"I'm glad to have the opportunity to choose what kind of care I receive while I still can." Is correct. This statement reflects the understanding that advance directives offer the opportunity to make decisions about the type of care the client wishes to receive or avoid, empowering them to express their preferences while they are still able to do so.

Choice D Reason:

"Once I fill out my living will, there will be a 1-month delay before it is legally binding." Is incorrect. There isn't typically a standardized waiting period before an advance directive becomes legally binding. The legal validity and activation of advance directives vary by region, but they usually become effective immediately upon completion unless stated otherwise or specific requirements apply.

A. Include the family member in providing care for the client. B. Describe a personal experience with the death of a family member. C. Ask if they have had prior experience with the death of a family member. D. Suggest that the family member contact a grief counselor.

Correct Answer is C

Explanation

Choice A Reason:

Including the family member in providing care for the client is incorrect. While involving the family in care might be helpful for some, not all family members might feel comfortable or capable of participating in direct care during such an emotional and difficult time. Asking their preferences and respecting their boundaries is crucial.

Choice B Reason:

Describing a personal experience with the death of a family member is incorrect. Sharing personal experiences could potentially be inappropriate or overwhelming for the family member. It might inadvertently shift the focus away from the client's needs and emotions.

Choice C Reason:

Asking if they have had prior experience with the death of a family member is correct. This approach allows the nurse to understand the family member's prior experiences with death, providing insights into their understanding, fears, and expectations. It also helps the nurse tailor their support accordingly, acknowledging their emotions and offering assistance that aligns with their comfort level.

Choice D Reason:

Suggesting that the family member contact a grief counselor is incorrect. While grief counseling might be beneficial, suggesting it immediately might not address the family member's immediate need or desire to help in the moment. It's essential to acknowledge their offer to help and offer immediate support or guidance that aligns with their comfort level.

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