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.

Clamp the catheter tubing below the needleless port.

Clamp the catheter tubing for 60 min.

Remove 45 mL of urine from the catheter with a syringe.

Answer and Explanation

The Correct Answer is B

A) Place the specimen in a clean specimen cup. - Urine collected from an indwelling urinary catheter should be obtained using a sterile technique, not placed directly into a clean specimen cup.
B) Clamping the catheter tubing for 10–30 minutes before collecting the sample allows fresh urine to accumulate in the tubing, ensuring a more accurate culture result. The urine should be collected from the designated port using aseptic technique, not from the catheter bag, as stagnant urine may contain contaminants.

C) Clamp the catheter tubing for 60 min. - Clamping the tubing for an extended period can cause urinary retention and discomfort for the client. It is not appropriate for collecting a urine specimen.
D) Only 3–5 mL of urine is needed for a culture. The nurse should collect the appropriate small amount to avoid unnecessary removal of urine.

Nursing Test Bank

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Correct Answer is B

Explanation

A) Administering vaginal cream to a client who has a vaginal infection - This task involves administration of medication, which typically falls within the scope of licensed nursing practice.

B) Providing postmortem care for a client who has just died - When delegating tasks to assistive personnel, nurses can assign activities such as providing postmortem care.
C) Suctioning a tracheostomy for a client who has a recent head injury - Suctioning a tracheostomy requires specialized training and is typically performed by licensed nursing staff.
D) Changing a peripheral IV dressing for a client who is postoperative - Changing an IV dressing is a task that require skills of a licensed nurse hence cannot be delegated to an assistive personnel.

Body System	Findings
Neurological	Alert and oriented to person, place, and time; deep tendon reflexes 4+
Musculoskeletal	Generalized weakness with equal bilateral muscle strength and mild leg cramping
Respiratory	: Lungs clear
Cardiovascular	: Heart rate irregular, Heart rate 95/min
Gastrointestinal	Bowel sounds hyperactive x 4 quadrants

A. deep tendon reflexes 4+ B. Heart rate irregular C. Bowel sounds hyperactive x 4 quadrants D. Generalized weakness with equal bilateral muscle strength and mild leg cramping E. Lungs clear F. Heart rate 95/min G. Alert and oriented to person, place, and time;

Correct Answer is ["A","B","C","D"]

Explanation

An irregular heart rhythm could indicate potential cardiovascular issues. Additionally, deep tendon reflexes graded at 4+ suggest hyperreflexia, which may be associated with neurological disorders and should be investigated further.

Hyperactive bowel sounds in all four quadrants could indicate gastrointestinal hypermotility, which might require prompt assessment to determine the underlying cause.

Generalized weakness and mild leg cramping also require follow-up to determine the cause.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is delegating client care to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Correct Answer is B

Explanation

Correct Answer is ["A","B","C","D"]

Explanation

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