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

Answer and Explanation

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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Correct Answer is A

Explanation

A. Return to the room to check and assess the patient:
Patient safety is always the first priority. The nurse must immediately assess the patient for adverse effects or reactions.

B. Administer the antidote to the patient immediately:
This is premature. An antidote is only given if a specific medication and reaction are identified.

C. Alert the charge nurse that a medication error has occurred:
This is necessary after assessing the patient. Reporting comes after immediate safety checks.

D. Complete proper documentation of the medication error in the patient's chart:
Documentation is important but should be done after the patient is assessed and stabilized.

A. Standing at his left side and holding his arm B. Standing at his left side and holding one arm around his waist C. Standing at his right side and holding his arm D. Standing at his right side and holding one arm around his waist

Correct Answer is D

Explanation

A. Standing at his left side and holding his arm:
The nurse should stand on the affected (weaker) side to provide support and prevent falls. Holding the arm is unsafe and does not offer adequate support.

B. Standing at his left side and holding one arm around his waist:
Being on the stronger (left) side does not offer the necessary support for the weaker (right) side.

C. Standing at his right side and holding his arm:
Although standing on the correct side, holding the arm can cause injury and does not provide a secure grip.

D. Standing at his right side and holding one arm around his waist:
The nurse should stand on the weaker (right) side and use a gait belt or support around the waist for safe ambulation.

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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?

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