A nurse is caring for a client who has pneumonia and is coughing up secretions. Which of the following actions should the nurse take first?

A. Stiffness in the lower extremities can occur due to lack of movement and muscle disuse. Prolonged immobility leads to muscle atrophy and contractures, causing stiffness and reduced range of motion. This is a common complication seen in clients who are bedridden or have limited mobility.
B. A reddened area over the sacrum indicates a potential pressure injury or pressure ulcer. Immobility increases the risk of pressure ulcers due to prolonged pressure on bony prominences, such as the sacrum. Regular repositioning and pressure relief strategies are essential to prevent skin breakdown in immobile clients.
C. Difficulty hearing certain types of sounds is not typically associated with immobility. It may be related to age-related changes in hearing or other auditory issues but is not a direct complication of immobility.
D. Difficulty moving the upper extremities can occur due to muscle weakness or disuse atrophy, which can result from immobility. However, it is less common compared to stiffness and difficulty in the lower extremities because upper extremities are often more frequently moved or exercised even in bedridden clients.

A. This instruction is more appropriate for female clients performing perineal hygiene before providing a clean-catch urine specimen. For straight catheterization, the nurse typically performs sterile technique, including cleansing the urethral meatus with an antiseptic solution as part of the procedure. The client's perineal area may be cleansed if necessary, but the primary focus is on maintaining sterile technique during catheter insertion.
B. When performing straight catheterization, the nurse inserts a sterile catheter into the client's bladder via the urethra to obtain urine directly. The urine is collected from the catheter itself as it drains into a sterile specimen container. It's essential to avoid touching the catheter's port or allowing it to come into contact with non-sterile surfaces to prevent contamination.
C. When inserting a Foley catheter (indwelling catheter), sterile water is used to inflate the balloon at the tip of the catheter after insertion into the bladder. For straight catheterization, a balloon is not typically inflated because the catheter is removed immediately after urine is obtained. Therefore, this step is not applicable in this context.
D. It is crucial to use a sterile specimen container to collect urine obtained via straight catheterization. This ensures that the specimen remains uncontaminated and suitable for culture and sensitivity testing, which requires accurate identification of any bacteria present in the urine.