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","C","E"]
Explanation
A. Growing urine cultures for up to 12 hours:
Nurses do not grow cultures; lab personnel handle this. The nurse’s role is collection and proper transport of specimens.
B. Labeling all specimens with date, time, and initials:
Correct labeling ensures proper identification and prevents errors in diagnosis and treatment.
C. Allowing the patient adequate time and privacy to void:
Respecting patient privacy encourages accurate specimen collection and maintains dignity.
D. Wearing gown, gloves, and mask for all specimen handling:
Gloves are necessary, but gowns and masks are not required unless splashing or isolation precautions are involved.
E. Transporting specimens to the laboratory in a timely manner:
Delays in transport can lead to contamination or degradation of the sample, affecting test accuracy.
F. Collecting the specimen from the drainage bag of an indwelling catheter:
Urine from the drainage bag is not sterile and is not appropriate for culture. It may yield inaccurate results
Correct Answer is A
Explanation
A. Do not give the medication:
Nurses should never administer medications prepared by someone else, as this violates the “right medication” and “right patient” principles.
B. Administer the medication just this once:
Even a one-time exception is unacceptable and compromises patient safety and nurse accountability.
C. Give the medication for any pain score greater than 8:
This does not address the issue of medication verification and safety.
D. Avoid the issue and pretend to not hear the request:
This is unprofessional. The nurse should actively refuse and explain the rationale.
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