The nurse is providing indwelling catheter care for a patient who is uncircumcised. What intervention will help prevent a catheter associated urinary tract infection?
Obtain daily urine specimens by opening the collection drainage system.
Keep the urine collection bag below the level of the bladder at all times.
Retract the foreskin to clean the catheter tubing and meatus outward leaving the foreskin retracted.
Change the indwelling catheter at least every one week.
The Correct Answer is B
A. Obtain daily urine specimens by opening the collection drainage system: Opening the drainage system increases the risk of introducing bacteria into the catheter, which can lead to infection.
B. Keep the urine collection bag below the level of the bladder at all times: Keeping the bag below the bladder prevents urine from back flowing into the bladder, which reduces the risk of infection.
C. Retract the foreskin to clean the catheter tubing and meatus outward, leaving the foreskin retracted: While the foreskin should be retracted for cleaning, it must always be returned to its normal position to prevent paraphimosis, a condition where the foreskin becomes trapped and restricts blood flow.
D. Change the indwelling catheter at least every one week: Routine catheter changes are not recommended unless there is an indication such as obstruction or infection. Unnecessary changes increase infection risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I will avoid individuals who were recently vaccinated." Patients with neutropenia should avoid live vaccines and exposure to individuals who recently received live vaccines (e.g., MMR, varicella) due to the risk of infection.
B. "I can have visitors so long as they are healthy." This is an appropriate statement. Visitors who are completely healthy and follow proper infection control measures can visit a neutropenic patient.
C. "I can have fresh flowers brought in." Fresh flowers and plants should be avoided due to the risk of fungal or bacterial contamination in the soil and water, which could lead to infection in an immunocompromised patient.
D. "I should avoid soft cheese." Patients with neutropenia should avoid unpasteurized soft cheeses (e.g., Brie, feta, blue cheese) as they can contain Listeria and other bacteria that pose a risk of infection.
Correct Answer is C
Explanation
A. Slough tissue is present: Slough tissue (yellow or white non-viable tissue) can be seen in stage III or IV ulcers but does not alone define a stage IV injury.
B. Adipose tissue is present: Fat (adipose tissue) exposure indicates a stage III ulcer, not necessarily stage IV.
C. Fascia tissue is present: Stage IV pressure injuries extend into deep tissues such as fascia, muscle, tendon, cartilage, or bone, distinguishing them from stage III ulcers.
D. Undermining is present: Undermining (tissue destruction extending under intact skin) can occur in both stage III and IV ulcers, so it is not a defining feature.
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