A nurse is caring for a client who has a prescription for warfarin.

Which of the following laboratory tests should the nurse monitor?

A) Coiling the tubing on the bed above the collection bag is incorrect because it can cause urine to flow back into the bladder, increasing the risk of infection and compromising the effectiveness of the drainage system. The tubing should be kept below the level of the bladder to ensure proper drainage.

B) Instructing the client to hold the drainage bag at waist height when ambulating is incorrect because the drainage bag should always be kept below the level of the bladder to prevent urine from flowing back into the bladder, which could lead to a urinary tract infection (UTI).

C) Securing the tubing with adhesive tape to the lower abdomen is correct because it helps prevent accidental pulling or tugging on the catheter, which could cause discomfort or dislodgement. Properly securing the tubing also helps maintain a continuous flow of urine and reduces the risk of infection.

D) Collecting a sterile specimen from the urinary drainage bag is incorrect because urine in the drainage bag is not considered sterile. If a sterile specimen is needed, it should be obtained by cleaning the catheter's sampling port with an antiseptic solution and withdrawing urine directly from the port using a sterile syringe.

Choice A Reason:

Blaming the assistive personnel without additional information or evidence may not be appropriate and should be investigated further.

Choice B Reason:

Mentioning that an incident report has been completed and sent to risk management is important for institutional record-keeping and follow-up but does not provide details about the incident itself.

Choice C Reason:

"Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom'." In the documentation of a client fall, it is important to include the client's own account of the incident, as this can provide valuable information about the circumstances surrounding the fall. Including direct quotes or statements from the client helps to accurately capture their perspective and can be useful for assessing the root causes of the fall and developing appropriate interventions to prevent future falls.

Choice D Reason:

Documenting that the client does not appear to have any injuries is relevant but does not provide information about the circumstances of the fall, which is important for a comprehensive understanding of the event.