The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel?
Kinking the catheter tubing to obtain a sterile urine specimen.
Emptying the colostomy drainage bag when 3/4 full.
Assessing placement of a Foley and securing the catheter tubing to the patient's thigh.
Placing the urinary catheter bag on the bed frame of the patient's bed after ambulation.
The Correct Answer is B
Choice A reason: Kinking catheter tubing to obtain a sterile urine specimen is outside the nursing assistive personnel (NAP) scope. This task requires sterile technique and clinical judgment to ensure sample integrity and prevent infection. It’s reserved for licensed nurses due to risks of contamination or catheter damage, which could lead to inaccurate diagnostics or patient harm.
Choice B reason: Emptying a colostomy drainage bag when 3/4 full is appropriate for NAP. This routine task involves measuring output and maintaining hygiene, aligning with NAP’s role in assisting with daily living activities and basic patient care under nurse supervision, ensuring patient comfort and preventing bag leakage or skin irritation.
Choice C reason: Assessing Foley catheter placement and securing tubing requires clinical judgment and specialized training. These tasks involve evaluating catheter function and preventing complications like dislodgement or infection, which are responsibilities of licensed nurses, not NAP, due to the need for professional expertise to ensure patient safety and catheter efficacy.
Choice D reason: Placing the catheter bag on the bed frame is inappropriate for NAP as it risks infection and catheter dysfunction. The bag must remain below bladder level to prevent urine backflow, a principle requiring nurse oversight, not NAP delegation, to avoid complications like urinary tract infections or bladder trauma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Scheduled toileting every 2 hours establishes a routine, compensating for dementia-related cognitive deficits in recognizing bladder cues. This promotes continence, reduces accidents, and maintains dignity, making it the most effective behavioral intervention.
Choice B reason: Indwelling catheters increase risks of urinary tract infections, skin breakdown, and discomfort, especially in dementia patients unable to communicate issues. They are a last resort, not appropriate for managing incontinence without medical necessity.
Choice C reason: Reminding a dementia patient to report urination needs is ineffective, as cognitive impairment limits their ability to recognize or communicate bladder signals. This approach does not address the underlying issue of incontinence.
Choice D reason: Adult diapers manage accidents but do not promote continence or address the behavior. They may reduce dignity and increase skin breakdown risk, making scheduled toileting a more proactive and dignified intervention.
Correct Answer is A
Explanation
Choice A reason: An ascending colon ostomy produces very liquid stool because this proximal colon segment primarily absorbs water and electrolytes. Minimal water reabsorption occurs here, resulting in high fluid content in the stool, unlike more distal colon segments where stool becomes more formed.
Choice B reason: A descending colon ostomy produces semi-formed stool. This segment further absorbs water, concentrating fecal matter compared to the ascending colon. The stool is less liquid, reflecting increased water reabsorption, making it less characteristic of very liquid output.
Choice C reason: A sigmoid colon ostomy produces formed stool. The sigmoid colon stores and compacts feces, with significant water reabsorption, resulting in solid, less frequent output. This contrasts with the liquid stool expected from more proximal ostomies like the ascending colon.
Choice D reason: A transverse colon ostomy produces semi-liquid to semi-formed stool. Positioned between the ascending and descending colon, it absorbs more water than the ascending colon but less than the sigmoid, resulting in thicker output, not very liquid stool.
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