A nurse is evaluating a patient who has a stage 1 pressure injury. What findings should the nurse anticipate?

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.

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.