A nurse is evaluating a nursing assistive personnel's (AP) care for a patient with an indwelling catheter. Which action by the AP will cause the nurse to intervene?
Emptying the drainage bag when half full
Kinking the catheter tubing to obtain a urine specimen
Placing the drainage bag on the side rail of the patient's bed
Securing the catheter tubing to the patient's thigh
The Correct Answer is C
A. Emptying the drainage bag when half full:
This helps prevent backflow and tension on the catheter. It is an appropriate action.
B. Kinking the catheter tubing to obtain a urine specimen:
While not ideal, temporary kinking (with care) may be done to collect a specimen. This is not the worst safety breach.
C. Placing the drainage bag on the side rail of the patient's bed:
The bag must be kept below bladder level to prevent reflux and infection. Side rails can move, leading to unsafe positioning.
D. Securing the catheter tubing to the patient's thigh:
Properly securing the catheter prevents traction and reduces the risk of injury or dislodgement.
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Related Questions
Correct Answer is D
Explanation
A. Disconnect the drainage tube from the catheter:
This breaks the closed system and increases the risk of infection. Not appropriate.
B. Withdraw urine from the closed system drainage bag:
The urine in the bag is not fresh and may be contaminated, leading to inaccurate results.
C. Empty contents of the drainage bag into the specimen cup:
This is not a sterile method and would not provide a reliable culture result.
D. Attach a sterile syringe to the catheter port to withdraw urine:
This is the correct sterile technique for obtaining a sample from an indwelling catheter without contaminating the system.
Correct Answer is C
Explanation
A. Inform the patient that she is counting respirations:
This may lead the patient to alter their breathing pattern, making the result inaccurate.
B. Do not touch the patient until completed:
Touch is not contraindicated, and hand placement on the chest can assist in counting if needed.
C. Obtain without the patient knowing:
This is correct. Most accurate respiratory assessments are done while appearing to check pulse, to prevent voluntary changes in breathing.
D. Estimate respirations:
Estimating is not acceptable and may lead to inaccurate data that affects patient care.
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