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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
"I'll use focused breathing to control my pain." Is incorrect. Focused breathing is a relaxation technique that can complement guided imagery, but it's not specifically imagery-based. It's more aligned with techniques like mindfulness or deep breathing exercises.
Choice B Reason:
"I'll learn to notice the sensation of muscle tension." Is incorrect. Noticing muscle tension is a part of progressive muscle relaxation, a different technique aimed at reducing physical tension, which is different from guided imagery.
Choice C Reason:
"I'll think about my grandfather's farm to reduce pain." Is correct. Guided imagery involves focusing on specific mental images or scenarios to promote relaxation, reduce stress, and manage pain. Imagining a peaceful or pleasant place, like the client's grandfather's farm, can serve as a distraction and help reduce pain perception.
Choice D Reason:
"I'll listen to my favorite music to take my mind off the pain." Is incorrect. Listening to music can be a distraction technique, but it's not specifically guided imagery. While it might help in managing pain by diverting attention, it's not rooted in imagery-focused mental visualization.
Correct Answer is B
Explanation
Choice A Reason:
"Aren't you interested in learning how to perform this test?" is incorrect. This response might come across as accusatory or judgmental, potentially making the client feel uncomfortable or defensive, further hindering communication.
Choice B Reason:
"Let's talk about what you're thinking." Is correct. This response acknowledges the client's distraction and aims to understand and address their thoughts or concerns that might be hindering their focus. It invites the client to express any worries or questions they might have, allowing the nurse to provide reassurance or clarification.
Choice C Reason:
"I'll discuss this with your partner instead." Is incorrect. Redirecting the conversation to the client's partner without understanding the client's concerns directly could undermine the client's autonomy and miss the opportunity to address their needs.
Choice D Reason:
"Is this something you think you can do?" is incorrect. While this question aims to assess the client's confidence, it might not effectively address the underlying reason for the client's distraction or encourage open communication about their concerns.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.