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.

Answer and Explanation

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

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Correct Answer is A

Explanation

A non-tender, protruding abdomen is a normal finding for a 2- year-old toddler. This is due to the immature development of the abdominal muscles and the relatively large size of the liver and kidneys in relation to the rest of the body.

Choice B is wrong because the head circumference should be equal to or less than the chest circumference by age 2. A head circumference that exceeds the chest circumference could indicate hydrocephalus or other neurological problems.

Choice C is wrong because the fontanels, or soft spots on the skull, should be closed by the age of 18 months. Palpable fontanels could indicate dehydration, malnutrition, or congenital disorders.

Choice D is wrong because the natural loss of deciduous teeth, or baby teeth, usually begins around age 6. Premature loss of teeth could indicate dental caries, trauma, or endocrine disorders.

A. “A nurse will draw blood from your baby’s inner elbow.” B. “Your baby will be given 2 ounces of water to drink prior to the test.” C. “This test will be repeated when your baby is 2 months old.” D. “This test should be performed after your baby is 24 hours old.”

Correct Answer is D

Explanation

This test should be performed after your baby is 24 hours old. This is because newborn genetic screening is a set of laboratory tests that detect a set of known genetic diseases that can affect a child’s long-term health or survival. The test is performed on a blood sample obtained from a heel prick when the baby is two or three days old. Performing the test after 24 hours ensures that the baby has had enough time to metabolize certain substances that could interfere with the accuracy of the test.

Choice A is wrong because the blood sample is not drawn from the baby’s inner elbow, but from the heel.

Choice B is wrong because the baby does not need to drink water prior to the test, as this could dilute the blood sample and affect the results.

Choice C is wrong because the test does not need to be repeated when the baby is 2 months old, unless there is a positive or inconclusive result from the first test.

Newborn genetic screening is important for early detection and intervention of certain conditions that can cause serious health problems or disability if left untreated. Parents should be informed about the benefits and limitations of the test, as well as their rights and options regarding consent and confidentiality.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching?

Correct Answer is D

Explanation

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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?