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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Chilling the irrigant prior to the procedure is not recommended. Cold irrigant can cause discomfort and potentially lead to vasoconstriction, which can impede the healing process.
Choice B rationale
Irrigating the wound until the solution that is draining is clean is a standard practice in wound care. This helps to ensure that all debris and potential contaminants are removed from the wound.
Choice C rationale
Holding the tip of the syringe at least 13 cm (0.5 in) above the wound while irrigating is not a standard practice. The syringe should be held close to the wound to ensure effective irrigation.
Choice D rationale
Flushing the wound from the most contaminated area to the cleanest area is not a standard practice. The wound should be irrigated from the cleanest to the dirtiest area to prevent the spread of contamination.
Correct Answer is A
Explanation
Choice A rationale
Donning sterile gloves before inserting the indwelling urinary catheter is a critical step to prevent infection. The urinary tract is normally sterile, and using sterile gloves helps maintain this sterility during the procedure.
Choice B rationale
Applying an oil-based lubricant to the indwelling urinary catheter is not recommended. Oil- based lubricants can damage latex catheters and increase the risk of infection. A water-soluble lubricant is typically used.
Choice C rationale
Using one cotton swab to clean the client’s genitalia is not sufficient. Proper cleaning and disinfection of the area are crucial to prevent introducing bacteria into the urinary tract during catheter insertion.
Choice D rationale
Testing the balloon on the indwelling urinary catheter before insertion is not typically done. The balloon is usually inflated with sterile water once the catheter is in place to ensure that it remains in the bladder.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.