A nurse is collecting a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?
Remove 45 mL of urine from the catheter with a syringe.
Clamp the catheter tubing for 60 min.
Clamp the catheter tubing below the needleless port
Place the specimen in a clean specimen cup.
The Correct Answer is A
Choice A Reason:
Removing 45 mL of urine from the catheter with a syringe is correct. To obtain a sterile urine specimen from an indwelling urinary catheter, the nurse should use a sterile syringe to aspirate a specific volume of urine from the catheter tubing. This method ensures minimal contamination and an accurate representation of the urine in the bladder at that moment.
Choice B Reason:
Clamping the catheter tubing for 60 min is incorrect.
Clamping the catheter tubing can lead to potential complications such as urinary retention, backflow of urine, or discomfort for the client. It's not a standard practice and could compromise the client's care.
Choice C Reason:
Clamping the catheter tubing below the needleless port is incorrect.
Clamping the catheter tubing can disrupt the urinary drainage and potentially cause issues like urinary stasis or increase the risk of infection. It's not an appropriate method for collecting a sterile urine specimen.
Choice D Reason:
Place the specimen in a clean specimen cup is incorrect. While placing the specimen in a clean cup is necessary, the method of collecting a urine sample from an indwelling catheter involves using a sterile syringe to aspirate a specific volume of urine directly from the catheter tubing, rather than pouring it into a cup from the collection bag.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
To an employer for a pre-employment screening is correct. Generally, healthcare information disclosure to an employer for pre-employment screening requires the client's written consent. The Health Insurance Portability and Accountability Act (HIPAA) and other privacy regulations typically protect a client's health information from disclosure to employers without explicit authorization from the client.
Choice B Reason:
To a medical interpreter service on behalf of a client is incorrect. In situations where a medical interpreter service is required to facilitate communication between the healthcare provider and the client, limited disclosure of health information may be necessary to ensure proper care. However, the information shared should be relevant to the immediate healthcare needs and should not exceed what's necessary for effective communication.
Choice C Reason:
To a family member when the client is not available is incorrect. In certain circumstances, especially if the client is incapacitated or unavailable, disclosing limited health information to a family member might be necessary for the client's best interests, such as for care coordination or emergencies. However, the information shared should be limited to what's essential and relevant to the situation.
Choice D Reason:
To an insurance agency in regard to a life insurance policy is incorrect. Health information disclosure to an insurance agency might be permitted in the context of processing a life insurance policy, typically under the Health Insurance Portability and Accountability Act (HIPAA) and as allowed by state laws. However, this disclosure is usually limited to information necessary for underwriting the policy and may not require the client's explicit written consent.
Correct Answer is A
Explanation
Choice A Reason:
Measuring the intake and output of a client who has received furosemide is correct. This task involves recording and measuring fluid intake and output, which is typically within the scope of practice for assistive personnel. It requires accurate documentation and doesn't involve making clinical judgments.
Choice B Reason:
Reinforcing teaching with a client about crutch-gait walking is incorrect. Teaching and instructing clients about specific medical procedures or techniques usually require specialized knowledge and assessment skills, typically within the nurse's scope of practice.
Choice C Reason:
Checking a client's peripheral IV site for redness or swelling is incorrect. Assessing for redness or swelling at an IV site involves clinical judgment and assessment skills to identify potential complications. This task is better suited for a licensed nurse who can interpret findings and take appropriate action if needed.
Choice D Reason:
Assessing the pain level of a client who has received acetaminophen is incorrect. Assessing pain levels involves subjective interpretation and understanding of pain scales, which generally falls under the scope of licensed healthcare providers who can evaluate and manage pain interventions based on assessments.
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