A nurse is caring for a client who has an indwelling urinary catheter.
The nurse notes that sediment is present in the urine.
Which of the following actions should the nurse take to obtain a sterile urine specimen?
Unclamp the collection port below the bag.
Obtain the specimen from the retention port.
Disconnect the catheter from the collection tubing.
Use the balloon port to obtain the sterile specimen.
The Correct Answer is B
This is because the retention port is a sterile site that can be accessed by a syringe to aspirate urine without contaminating the specimen or the closed drainage system. The retention port should be cleaned with an alcohol swab before inserting the syringe. The specimen should be transferred to a sterile container and labeled appropriately.
Choice A is wrong because unclamping the collection port below the bag would allow urine to flow out of the bag, which is not sterile and may contain bacteria or sediment.
Choice C is wrong because disconnecting the catheter from the collection tubing would break the closed drainage system and increase the risk of infection.
Choice D is wrong because using the balloon port to obtain the sterile specimen would deflate the balloon that holds the catheter in place and cause trauma to the bladder wall.
Normal ranges for urine characteristics vary depending on the type of analysis, but some general parameters are:
• Color: pale yellow to amber
• Clarity: clear or slightly cloudy
• Odor: faint aromatic
• pH: 4.5 to 8.0
• Specific gravity: 1.005 to 1.030
• Protein: <150 mg/24 hr
• Glucose: negative
• Ketones: negative
• Blood: negative
• Nitrites: negative
• Leukocyte esterase: negative
• Bacteria: <10,000 CFU/mL
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
According to the flashcards from Quizlet, a nurse should monitor a client who is at 33 weeks of gestation following an amniocentesis for contractions, as they are a sign of preterm labor and possible uterine rupture. An amniocentesis is a procedure that involves inserting a needle into the amniotic sac to obtain a sample of amniotic fluid for testing. It can cause complications such as bleeding, infection, leakage of fluid, and injury to the fetus or placenta.
Choice A is wrong because it is not a common complication of amniocentesis.
Epigastric pain is more likely to be associated with preeclampsia, a condition that causes high blood pressure and proteinuria in pregnancy. Epigastric pain can indicate severe preeclampsia or HELLP syndrome (hemolysis, elevated liver enzymes, low platelets), which are life- threatening complications that require immediate medical attention.
Choice B is wrong because it is not a direct result of amniocentesis.
Hypertension can occur in pregnancy due to various factors, such as chronic hypertension, gestational hypertension, preeclampsia, or eclampsia. Hypertension can increase the risk of complications such as placental abruption, fetal growth restriction, preterm birth, and maternal stroke.
Choice D is wrong because it is not a typical complication of amniocentesis.
Vomiting can occur in pregnancy due to various causes, such as morning sickness, gastroenteritis, food poisoning, or hyperemesis gravidarum. Vomiting can lead to dehydration, electrolyte imbalance, weight loss, and malnutrition if not treated properly.
Some normal ranges that are relevant for this question are:
- The normal gestational age for delivery is between 37 and 42 weeks.
A baby born before 37 weeks is considered preterm and may have complications such as respiratory distress syndrome, bleeding in the brain, infection, or low blood sugar.
- The normal fetal heart rate is between 110 and 160 beats per minute.
A fetal heart rate below 110 or above 160 can indicate fetal distress or hypoxia.
- The normal amniotic fluid index (AFI) is between 8 and 18 cm.
An AFI below 5 cm is considered oligohydramnios and can indicate fetal growth restriction, kidney problems, or rupture of membranes.
An AFI above 24 cm is considered polyhydramnios and can indicate fetal anomalies, diabetes mellitus, or Rh incompatibility.
Correct Answer is C
Explanation
This is because a peak flow meter measures how fast you can push air out of your lungs when you blow out as hard and as fast as you can. This is called peak expiratory flow rate (PEFR) or peak expiratory flow (PEF). It shows how open the airways are in the lungs and can help detect early signs of worsening asthma.
Choice A is wrong because maintaining a semi-Fowler’s position during testing is not necessary. You can sit or stand up straight, but make sure you do it the same way each time.
Choice B is wrong because placing tongue on the mouthpiece of the meter can block the air flow and affect the accuracy of the measurement. You should close your lips tightly on the mouthpiece instead.
Choice D is wrong because recording the average of the readings is not recommended.
You should record the highest of the three readings on a sheet of paper, calendar or in your asthma diary. This is your daily peak flow.
Normal ranges for peak flow vary depending on age, height, gender and race. You can use a chart or calculator to find out your predicted normal peak flow based on these
factors. However, it is more important to find out your personal best peak flow by performing peak flow testing twice a day for two weeks when your asthma is under good control. Your personal best peak flow will be used to create your asthma action plan with your healthcare provider.
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