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.

Placing the drainage bag on the side rail of the patient’s bed.

Kinking the catheter tubing to obtain a urine specimen.

Securing the catheter tubing to the patient’s thigh.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Emptying the drainage bag when half full is a correct action by the AP4. It is important to empty the drainage bag regularly to prevent infection and maintain accurate intake and output records.

Choice B rationale

Placing the drainage bag on the side rail of the patient’s bed is an incorrect action by the AP4. The drainage bag should be placed below the level of the bladder to prevent backflow of urine, which can lead to infection.

Choice C rationale

Kinking the catheter tubing to obtain a urine specimen is an incorrect action by the AP4. This can cause discomfort to the patient and potentially damage the catheter.

Choice D rationale

Securing the catheter tubing to the patient’s thigh is a correct action by the AP4. This helps to prevent pulling on the catheter, which can cause discomfort and potential damage to the urethra.

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Correct Answer is B

Explanation

Choice A rationale

A stoma may appear red and moist immediately after surgery, similar to the inside of the mouth. A purplish color could indicate a lack of blood supply to the stoma, which is a medical emergency.

Choice B rationale

A small amount of bleeding around the stoma is normal, especially when cleaning the area or changing the ostomy appliance. This is because the stoma contains blood vessels and has a rich blood supply.

Choice C rationale

Fecal output from a colostomy can be expected within 2 to 4 days after surgery. It is not typical to see output within 24 hours.

Choice D rationale

An increase in the intake of raw vegetables is not necessary after a colostomy. In fact, some people may find certain raw vegetables difficult to digest and they may cause gas or odor.

A. Fill the balloon with the recommended sterile water. B. Remove the catheter, wipe with alcohol, and reinsert after lubrication. C. Leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter. D. Discard the catheter and begin again.

Correct Answer is C

Explanation

If the nurse suspects the catheter is not in the urethra, they should leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is educating a patient who recently had a colostomy. What information should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is inserting a catheter into a female patient. When the nurse inserts the catheter, no urine is obtained. The nurse suspects the catheter is not in the urethra. What should the nurse do?

Correct Answer is C

Explanation

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