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.

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Correct Answer is A

Explanation

A) Recheck the client's SaO2 level after having the client cough and clear their throat.

- This action helps determine if the low SaO2 level is due to a transient cause such as mucus or secretions blocking the airway.
B) Notify the charge nurse of the client's condition. - While important, this action should come after assessing and addressing the client's immediate needs.
C) Review the client's most recent SaO2 level in the medical record. - This information may provide context but does not address the current low SaO2 level.
D) Check the client's medical records to see which medications were recently admitted. - Medications may contribute to respiratory issues, but addressing the client's immediate respiratory distress takes priority.

A. "We will use an electric blanket to keep your partner warm." B. "Encourage your partner to eat three large meals each day." C. "Assume your partner can hear you, even if they do not respond." D. "Opioids will be restricted if your partner develops respiratory distress."

Correct Answer is C

Explanation

A) "We will use an electric blanket to keep your partner warm." - While maintaining warmth is important, this statement does not address communication or understanding between the partner and the client.
B) "Encourage your partner to eat three large meals each day." - Encouraging large meals may not be appropriate for a client at end-of-life care, and this statement doesn't address communication either.
C) "Assume your partner can hear you, even if they do not respond." - This statement acknowledges the importance of communication and connection with the client, even if they are not responsive.

D) "Opioids will be restricted if your partner develops respiratory distress." - This statement may be relevant in certain contexts but is not as directly related to communication and support for the partner.

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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

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