A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?
Secure the tubing with adhesive tape to the lower abdomen.
Instruct the client to hold the drainage bag at waist height when ambulating
Coil the tubing on the bed above the collection bag.
Collect a sterile specimen from the urinary drainage bag
The Correct Answer is A
A. Secure the tubing with adhesive tape to the lower abdomen: Properly securing the catheter tubing prevents tension on the catheter, reduces the risk of accidental dislodgment, and helps maintain a closed drainage system, which decreases the risk of infection.
B. Instruct the client to hold the drainage bag at waist height when ambulating: The drainage bag should always be kept below the level of the bladder to maintain proper urine flow and prevent backflow, which increases the risk of infection. Holding it at waist height is unsafe.
C. Coil the tubing on the bed above the collection bag: Placing tubing above the collection bag can allow urine to flow back toward the bladder, increasing the risk of urinary tract infection. Tubing should remain below bladder level.
D. Collect a sterile specimen from the urinary drainage bag: Sterile urine specimens should be obtained from a sampling port on the catheter using aseptic technique, not directly from the drainage bag, to avoid contamination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Gross motor skills: Rolling from abdomen to back, playing with feet, smiling responsively, and turning toward sounds are expected developmental milestones at 6 months of age. These findings indicate appropriate gross motor, social, and sensory development.
B. Temperature: A temperature of 37.4° C (99.3° F) is within the normal range for an infant. This finding does not suggest infection or illness and does not require provider notification.
C. Weight: At 6 months of age, an infant is expected to have approximately doubled their birth weight. This infant weighed 3.6 kg at birth and currently weighs 5.9 kg, which suggests inadequate weight gain and should be reported for further evaluation.
D. Feeding habits: Breastfeeding combined with small amounts of cereal and fruit three times daily is appropriate for a 6-month-old infant. There is no indication from the feeding history alone that intake is inappropriate.
Correct Answer is C
Explanation
A. Increased appetite: Radiation therapy often causes anorexia, nausea, and taste changes, leading to decreased appetite rather than an increase. Appetite suppression is a common side effect in clients receiving treatment for head and neck cancers.
B. Loose stools: Loose stools are not a typical side effect of external radiation to the throat. Gastrointestinal effects are more likely with abdominal or pelvic radiation.
C. Loss of taste: Radiation to the head and neck commonly affects the taste buds and salivary glands, resulting in dysgeusia or partial/complete loss of taste. This is an expected manifestation and can affect nutrition and quality of life.
D. Bladder infection: Radiation to the throat does not directly impact the urinary tract. Urinary tract infections are unrelated to external radiation for throat cancer unless there are other risk factors.
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