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 D
Explanation
This is because after puncturing the skin and the vein, the nurse needs to advance the catheter into the vein with the finger hub to ensure proper placement and prevent complications such as infiltration or phlebitis.
Choice A is wrong because flushing the catheter with saline should be done after securing the catheter to the skin with a transparent dressing and attaching a primed piece of extension tubing to the catheter.
Choice B is wrong because retracting the stylet should be done after advancing the catheter into the vein and releasing the tourniquet from the client’s arm.
Choice C is wrong because releasing the tourniquet should be done after advancing the catheter into the vein and before retracting the stylet.
Correct Answer is B
Explanation
A vertebroplasty is a procedure that injects cement into a fractured vertebra to help relieve pain and stabilize the spine. The recovery time for this procedure is usually short and the complications are rare.
Therefore, this client is most likely to be stable and ready for early discharge.
Choice A is wrong because a client who is receiving heparin for deep-vein thrombosis (DVT) needs close monitoring of their blood levels and clotting factors. Heparin is a blood thinner that prevents the clots from getting bigger or breaking loose and traveling to the lungs, which can cause a life-threatening condition called pulmonary embolism (PE).
This client is not a good candidate for early discharge.
Choice C is wrong because a client who has cancer and a sealed implant for radiation therapy needs to be isolated in a special room to prevent exposure of others to radiation. A sealed implant is a smallholder that contains a radioactive source that is placed inside or near the tumor to deliver high doses of radiation. This type of internal radiation therapy, also called brachytherapy, can last from several minutes to several days, depending on the type and dose of the radioactive source.
This client is not a good candidate for early discharge.
Choice D is wrong because a client who has COPD and a respiratory rate of 44/min has signs of respiratory distress and possible hypoxemia (low oxygen levels in the blood).
COP
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