Urinary tract infections associated with indwelling catheters are a major component of hospital-associated infections. What must nurses do to help decrease the incidence of these infections in their clients? (SELECT ALL THAT APPLY)

Maintain clean technique during catheter insertion.

Advocate for removal of indwelling catheters as soon as possible.

Use interventions that help clients to avoid initial catheterization.

Ensure fluid intake within client limitations.

Maintain urine collection bag at the level of the bladder.

Answer and Explanation

Correct Answer : A,B,C,D

Choice A rationale

Maintaining a clean technique during catheter insertion reduces the risk of introducing pathogens into the urinary tract. This helps prevent urinary tract infections (UTIs) by minimizing contamination.

Choice B rationale

Advocating for the removal of indwelling catheters as soon as possible is crucial because prolonged catheterization increases the risk of UTIs. Removing the catheter when it is no longer needed reduces exposure to potential infections.

Choice C rationale

Using interventions that help clients avoid initial catheterization decreases the likelihood of introducing pathogens into the urinary tract. Alternatives to catheterization, such as bladder training and intermittent catheterization, can reduce infection risk.

Choice D rationale

Ensuring fluid intake within client limitations helps maintain hydration and urine flow. Adequate fluid intake helps flush out bacteria from the urinary tract, reducing the risk of UTIs.

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Correct Answer is D

Explanation

Choice A rationale

Increasing the IV fluid flow rate is a critical task requiring clinical judgment and should not be delegated to an unlicensed nursing assistant. This task involves assessing the patient's hemodynamic status and fluid balance, which requires nursing expertise.

Choice B rationale

Listening to breath sounds in all lung fields is an assessment task that requires nursing knowledge and skills. It involves identifying normal and abnormal breath sounds, which is outside the scope of practice for an unlicensed nursing assistant.

Choice C rationale

Checking the abdominal dressing for bleeding is an assessment and monitoring task. It involves evaluating the wound site for signs of hemorrhage or infection, which requires nursing assessment skills.

Choice D rationale

Documenting the amount of output on the I&O sheet is a task that can be delegated to an unlicensed nursing assistant. This task involves recording measurements, which does not require clinical judgment and is within the assistant's scope of practice.

A. Tenesmus. B. Hyperactive bowel sounds. C. An enlarging abdominal girth. D. Anal fissures.

Correct Answer is C

Explanation

Choice A rationale

Tenesmus is a frequent urge to defecate, common in ulcerative colitis but not indicative of toxic megacolon. It results from inflammation and irritation of the rectal and colonic mucosa, causing discomfort and straining during bowel movements.

Choice B rationale

Hyperactive bowel sounds are associated with increased gastrointestinal activity, often seen in diarrheal states and early mechanical bowel obstruction but not typically linked to toxic megacolon. Toxic megacolon often presents with reduced or absent bowel sounds due to colonic paralysis.

Choice C rationale

An enlarging abdominal girth indicates distension, a significant sign of toxic megacolon. This condition involves extreme dilation of the colon, which can lead to severe abdominal distension due to trapped gas and stool. This can be life-threatening if not treated promptly.

Choice D rationale

Anal fissures are tears in the anal canal, common in chronic constipation or Crohn’s disease, not typically a sign of toxic megacolon. They cause pain and bleeding during bowel movements but do not indicate toxic megacolon.

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Urinary tract infections associated with indwelling catheters are a major component of hospital-associated infections. What must nurses do to help decrease the incidence of these infections in their clients? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client in the immediate postoperative period after an open cholecystectomy. Which task could be delegated to an unlicensed nursing assistant?

Correct Answer is D

Explanation

The nurse suspects that the client hospitalized with severe ulcerative colitis, may be developing the complication of toxic megacolon. Which assessment finding supports these suspicions?

Correct Answer is C

Explanation

The client asks about the use of a T-tube following an open cholecystectomy. The nurse's best response is that a T-tube:

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