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?
Place the specimen in a clean specimen cup.
Remove 45 mL of urine from the catheter with a syringe.
Clamp the catheter tubing below the needleless port.
Clamp the catheter tubing for 60 min.
The Correct Answer is C
Choice A rationale
Placing the specimen in a clean specimen cup is not appropriate for a urine culture and sensitivity test. A sterile specimen cup is required to avoid contamination and ensure accurate results.
Choice B rationale
Removing 45 mL of urine from the catheter with a syringe is incorrect. Only 5-10 mL of urine is needed for a culture and sensitivity test, and excessive removal can lead to inaccurate test results or sample contamination.
Choice C rationale
Clamping the catheter tubing below the needleless port is the correct action. This allows urine to accumulate in the tubing, providing a fresh and uncontaminated sample for the culture and sensitivity test.
Choice D rationale
Clamping the catheter tubing for 60 minutes is too long and can cause urine stasis, increasing the risk of catheter-associated urinary tract infections. The tubing should be clamped only for a short duration to collect an adequate sample. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Increased peripheral circulation is not a typical part of the aging process. In fact, aging is often associated with decreased circulation due to vascular changes and reduced cardiac output.
Choice B rationale
Constipation is more common in older adults due to factors like reduced intestinal motility, decreased fluid intake, and medication side effects, making it a relevant physiological change in aging.
Choice C rationale
Decreased muscle mass, or sarcopenia, is a common part of aging. It results from a combination of reduced physical activity, hormonal changes, and nutritional deficiencies.
Choice D rationale
A decreased cough reflex in older adults increases the risk of aspiration and respiratory infections. It results from changes in neurological function and reduced muscle strength.
Correct Answer is A
Explanation
Choice A rationale
Guided imagery involves the use of mental visualization to relieve stress and manage pain. By thinking about a peaceful setting, such as the client’s grandfather's farm, they can divert attention from the pain and enter a state of relaxation. This technique helps reduce pain perception by engaging the mind in positive, soothing imagery, which can lead to decreased stress and muscle tension.
Choice B rationale
Listening to music is a distraction technique rather than guided imagery. While it can help take the mind off pain, it does not involve the mental visualization process that is central to guided imagery. Music can help by shifting attention away from pain and providing a calming effect through auditory stimulation.
Choice C rationale
Focused breathing is a relaxation technique that can help manage pain through controlled breathing patterns. It helps reduce anxiety and physical tension by focusing on slow, deep breaths. However, it does not involve the imaginative visualization that characterizes guided imagery.
Choice D rationale
Noticing the sensation of muscle tension is part of body awareness techniques, which involve paying attention to and understanding bodily sensations. While this can help in managing pain by addressing muscle tension, it is different from the mental visualization process of guided imagery.
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