The home care nurse is caring for a patient with an indwelling urinary catheter after spinal cord The catheter is patent with clear yellow urine after being in place for 8 weeks. Which is the ap action of the nurse?
Request an order for a urinalysis with culture and sensitivity.
Irrigate the patient's catheter using 60 mL of sterile normal saline.
Remove the catheter immediately and notify the health care provider.
Contact the health care provider for an order to change the catheter.
The Correct Answer is D
A. Request an order for a urinalysis with culture and sensitivity:
There is no indication of infection (e.g., no cloudy urine, odor, or fever), so a C&S is not warranted at this point.
B. Irrigate the patient’s catheter using 60 mL of sterile normal saline:
Irrigation should only be done with a provider’s order or if there is a clear obstruction, which is not the case here.
C. Remove the catheter immediately and notify the health care provider:
Removing without an order or plan can put the patient at risk, especially with a spinal cord injury and potential retention issues.
D. Contact the health care provider for an order to change the catheter:
Long-term indwelling catheters are typically changed every 4 to 12 weeks to reduce infection risk and ensure function. This is the safest and most appropriate next step.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Right medication:
Giving the correct drug is important, but without confirming identity, it may be given to the wrong person.
B. Right patient:
This is the priority in this scenario where two patients have the same last name. Confirming identity using two identifiers (e.g., name and birth date) is critical.
C. Right dose:
A correct dose is important, but it assumes it’s given to the right patient.
D. Right route:
Administering via the correct route is essential but irrelevant if the wrong patient receives the drug.
Correct Answer is F,E,A,C,B,D
Explanation
A. Clean injection port:
This is done after clamping and before connecting the syringe to prevent introducing infection.
B. Inject prescribed solution:
Done only after the syringe is connected to the port.
C. Twist needleless syringe into port:
This ensures a secure and sterile connection before irrigation.
D. Remove clamp and allow to drain:
This step ensures the irrigant and urine can flow out properly after irrigation.
E. Clamp catheter just below specimen port:
Done early to allow retention of solution during irrigation and prevent backflow.
F. Draw up prescribed amount of sterile solution ordered:
First step—preparing the exact amount of irrigation fluid needed.
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