The nurse is initiating a 24-hour urine collection for a client with an indwelling urinary catheter. After emptying all the urine from the collection bag, which action is most important for the nurse to implement?

Start the collection time now and stop the collection the next day at the same time.

Provide catheter care at the urinary site to prevent contamination of the specimens.

Clamp the catheter to control urine flow during the collection period.

Label the collection container with the client’s name and start time.

Answer and Explanation

The Correct Answer is A

Choice A reason: Starting the collection time after emptying the bag ensures an accurate 24-hour urine sample, critical for diagnostic tests like creatinine clearance. This defines the collection period, per laboratory and diagnostic specimen collection protocols in nursing practice.

Choice B reason: Catheter care prevents infection but is not the most critical step for initiating a 24-hour collection. Starting the collection time ensures accurate timing, essential for valid results, per urinary specimen collection and infection control standards in nursing.

Choice C reason: Clamping the catheter is inappropriate, as it disrupts continuous urine flow, skewing the 24-hour collection. Starting the collection time ensures accurate sampling, critical for diagnostic accuracy, per urinary catheter management and laboratory protocols in nursing practice.

Choice D reason: Labeling the container is important but secondary to starting the collection time, which defines the 24-hour period for accurate results. Timing ensures valid diagnostic data, per specimen collection and laboratory standards in nursing practice for urine collections.

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Correct Answer is D

Explanation

Choice A reason: Administering an IV narcotic masks pain without addressing its cause. Pain at the PCI site may indicate hematoma or arterial injury, common post-PCI due to vessel trauma and tirofiban’s antiplatelet effects. Assessing the site identifies bleeding, critical to prevent complications like hemorrhage before providing analgesia.

Choice B reason: Adjusting the compression device without assessment risks worsening a hematoma, as excessive pressure impairs flow, while insufficient pressure fails to control bleeding. Tirofiban increases bleeding risk. Assessing for hematoma ensures proper management, preventing vascular complications, making adjustment premature without confirming the pain’s cause.

Choice C reason: Turning to a left side-lying position does not address PCI site pain, potentially from hematoma or arterial injury. Post-PCI, supine positioning minimizes site stress. Assessing for hematoma, exacerbated by tirofiban’s anticoagulation, is critical to detect bleeding, preventing complications like retroperitoneal hemorrhage over positional changes.

Choice D reason: Assessing the femoral PCI site for hematoma is essential, as pain may indicate bleeding, common post-PCI with tirofiban’s platelet inhibition. Hematoma can compress vessels, causing ischemia or rupture, requiring urgent intervention like compression or surgery. This addresses the pathophysiological risk, ensuring vascular stability and patient safety.

A. Evaluate amount of urinary output hourly. B. Clamp the catheter for 5 minutes hourly. C. Secure the ureteral catheter to the client’s leg. D. Report urine leakage around ureteral catheter.

Correct Answer is D

Explanation

Choice A reason: Evaluating urinary output hourly monitors renal function post-ureterolithotomy, as obstruction or complications may reduce output. However, urine leakage around the catheter suggests dislodgement or ureteral injury, risking peritonitis or infection. Reporting leakage is more urgent, as it indicates a critical catheter malfunction requiring immediate medical attention.

Choice B reason: Clamping the ureteral catheter risks obstructing urine flow, increasing pressure and causing ureteral damage or reflux, potentially leading to hydronephrosis or infection. Leakage around the catheter is a more pressing issue, indicating possible perforation or displacement, necessitating urgent reporting to prevent severe complications.

Choice C reason: Securing the catheter prevents dislodgement but is routine. Urine leakage suggests a critical issue like catheter malfunction or ureteral injury, which could cause peritonitis or fistula. Reporting leakage takes precedence, as it addresses a potentially life-threatening complication, ensuring timely intervention over standard catheter care.

Choice D reason: Reporting urine leakage is critical, as it may indicate catheter displacement or ureteral perforation, risking peritonitis or infection. Leakage suggests the catheter fails to drain urine properly, a serious post-surgical issue requiring immediate assessment, potentially via imaging or surgical correction, to prevent renal or systemic complications.

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The nurse is initiating a 24-hour urine collection for a client with an indwelling urinary catheter. After emptying all the urine from the collection bag, which action is most important for the nurse to implement?

Nursing Test Bank

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Correct Answer is D

Explanation

Following a ureterolithotomy, the client has a ureteral catheter in place. Which intervention should the nurse implement?

Correct Answer is D

Explanation

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