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 C
Explanation
A. "Yes! I am sure you are excited to finally eat something. Let's set the head of the bed up." This statement misleads the patient by suggesting they can eat orally, which contradicts the purpose of parenteral nutrition (IV nutrition).
B. "Let me have the provider come explain to you what parenteral nutrition is." While the provider can clarify details, the nurse should explain basic information about parenteral nutrition immediately rather than deferring the question.
C. "Unfortunately, no. We are going to be providing you with nutrition through your vein." This provides a clear, direct, and simple explanation of parenteral nutrition (IV nutrition) while acknowledging the patient's interest in food.
D. "No, we will be putting in a tube that will go from your nose to your stomach to help you eat." This describes enteral nutrition (NG tube feeding), which is different from parenteral nutrition (IV feeding).
Correct Answer is A
Explanation
A. Palpate for pedal pulses: Cool skin may indicate poor circulation or ischemia. Checking pedal pulses helps assess blood flow. This step provides essential information about the vascular status of the patient's foot, guiding further interventions.
B. Turn the patient every three hours: Patients on bedrest should be turned every 2 hours, not every 3 hours, to prevent pressure injuries.
C. Document the stage 1 pressure injury: Blistering indicates at least a Stage 2 pressure injury, not Stage 1. The nurse must assess further before staging.
D. Elevate bilateral heels: Once assessment confirms the need, elevating the heels can help reduce pressure and promote circulation, potentially preventing further damage and aiding in the healing process.
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