The nurse is caring for a client with an indwelling catheter. The client asks the nurse if the drainage bag can be placed on the floor. How should the nurse respond?
"The drainage bag needs to be clipped to the edge of the mattress for ease of access."
"The drainage bag needs to be attached to the bed side-rail to reduce risk of pulling."
"The drainage bag needs to be attached to the bedframe to reduce risk of infection."
"The drainage bag needs to be secured on your inner thigh to reduce risk for injury."
The Correct Answer is C
Rationale:
A. Clipping the drainage bag to the edge of the mattress is incorrect. This placement does not maintain the bag below the bladder in a safe and stable manner and can increase the risk of accidental contamination or infection.
B. Attaching the drainage bag to the bedside rail is unsafe. The bag can swing, kink, or pull on the catheter, increasing the risk of urethral trauma and infection.
C. Attaching the drainage bag to the bedframe is correct. Securing the bag to a stable part of the bedframe keeps it below the level of the bladder, which promotes gravity drainage, prevents backflow of urine, and reduces the risk of catheter-associated urinary tract infection (CAUTI). This method also prevents accidental pulling or disconnection of the catheter.
D. Securing the drainage bag on the inner thigh is used for leg bags, which are typically for ambulatory clients. Standard bedside drainage bags are not placed on the thigh, as this could interfere with proper drainage and increase infection risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
Step 1: Use the formula
Number of capsules = Desired dose ÷ Dose available
Step 2: Insert known values
Desired dose = 300 mg
Dose available = 150 mg
Number of capsules = 300 ÷ 150
Number of capsules = 2
Correct Answer is A
Explanation
Rationale:
A. Suctioning the tracheostomy of a client who is desaturating and coughing is the highest priority action. This client is showing signs of airway obstruction and hypoxia, which are life-threatening conditions. Immediate intervention is required to restore airway patency and oxygenation. Airway emergencies always take precedence over other tasks because without oxygen, cellular and organ function can quickly deteriorate.
B. Calling the healthcare provider to report a critical lab result is important for client care, but it is not as urgent as an airway emergency. While critical labs may indicate a serious condition, the client’s immediate threat to life comes first.
C. Documenting that the client with a belt restraint is free from injury is necessary for legal and safety purposes, but it is a non-urgent task. It can be completed after attending to clients with acute, life-threatening needs.
D. Inserting an IV catheter for a client who has a STAT antibiotic ordered is urgent for timely medication administration, but it is secondary to managing a client who is experiencing acute hypoxia. Airway and oxygenation take priority over medication administration.
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