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?
Coil the tubing on the bed above the collection bag.
Instruct the client to hold the drainage bag at waist height when ambulating.
Collect a sterile specimen from the urinary drainage bag.
Secure the tubing with adhesive tape to the lower abdomen
The Correct Answer is D
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) 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.
D) 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.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is A
Explanation
During a mass casualty event, it is crucial for the nurse to assess and determine the acuity level (severity) and number of casualties who will be arriving at the healthcare facility. This information helps in planning and organizing resources, triaging patients based on their needs, and ensuring that appropriate care is provided to those who require immediate attention.
Delegating tasks to emergency health care specialists is a role that may be performed by a nurse in a leadership or supervisory position. However, the immediate priority for the nurse is to assess and triage incoming casualties.
Providing informational updates to members of the media is usually handled by designated spokespersons or communication specialists within the healthcare facility or incident command system. Nurses are primarily focused on patient care and should not be responsible for media communication during a mass casualty event.
Assisting in discharging stable clients to home is not directly related to the immediate response and care of casualties from a mass casualty event. The nurse's focus in such situations is primarily on the management of the incoming casualties and ensuring the availability of resources and care for those who require immediate attention.
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