Which interventions should the nurse implement to prevent a catheter-associated urinary tract infection (CAUTI)? (Select all that apply)

Flush catheter system daily

Obtain a urine specimen for culture every 24 hours

Secure the catheter to prevent movement

Inspect urine for color, odor, and consistency

Maintain a closed drainage system

Answer and Explanation

Correct Answer : C,E

Choice A reason: Flushing the catheter system daily is not recommended for CAUTI prevention. It disrupts the closed system, increasing the risk of introducing pathogens into the bladder. Maintaining a sterile, closed drainage system is critical to prevent bacterial entry, and flushing is only indicated for specific blockages, not routine care.

Choice B reason: Obtaining a urine specimen for culture every 24 hours is not a preventive measure for CAUTI. Routine culturing is unnecessary unless infection is suspected, as it increases manipulation of the catheter system, risking contamination. Cultures are diagnostic, not preventive, and frequent sampling may introduce bacteria, counteracting infection control efforts.

Choice C reason: Securing the catheter prevents movement, reducing trauma to the urethra and bladder mucosa. Movement can cause microtears, allowing bacterial entry and colonization, leading to CAUTI. Proper anchoring ensures the catheter remains stable, minimizing irritation and maintaining the integrity of the urinary tract’s natural barriers against infection.

Choice D reason: Inspecting urine for color, odor, and consistency monitors for signs of infection but does not prevent CAUTI. Changes like cloudiness or foul odor indicate an existing infection, not prevention. While useful for early detection, it is a reactive measure, not a proactive intervention to reduce the incidence of catheter-related infections.

Choice E reason: Maintaining a closed drainage system is critical for CAUTI prevention. A closed system minimizes bacterial entry into the catheter and bladder by preventing disconnection or external contamination. Breaks in the system, such as during bag changes, increase infection risk, making this a key intervention to reduce pathogen introduction.

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Correct Answer is B

Explanation

Choice A reason: Checking the client’s temperature hourly monitors for transfusion reactions but does not prevent them. Fever may indicate a reaction, but prevention relies on ensuring blood compatibility and proper administration. Monitoring is a reactive measure, not a proactive step to avoid mismatches or errors causing hemolytic or febrile reactions.

Choice B reason: Verifying the client’s identity and blood type with another nurse is critical to prevent transfusion reactions. Mismatched blood types cause hemolytic reactions due to antibody-mediated destruction of donor red cells. Double-checking ensures the correct blood unit is administered, preventing life-threatening immunological responses and ensuring patient safety during transfusion.

Choice C reason: Administering diphenhydramine may prevent mild allergic reactions to blood transfusions, such as hives, but it does not address severe hemolytic reactions caused by ABO incompatibility. It is not routinely given prophylactically unless the client has a history of allergic reactions, making it less critical than verifying blood compatibility.

Choice D reason: Infusing blood over 6 hours increases the risk of bacterial growth and hemolysis in the blood unit, as transfusions should typically be completed within 4 hours. Prolonged infusion does not prevent reactions and may cause complications, making it an incorrect action for ensuring safe transfusion practices.

A. Impaired gas exchange B. Activity intolerance C. Imbalanced nutrition: less than body requirements D. Impaired oral mucous membranes

Correct Answer is A

Explanation

Choice A reason: Impaired gas exchange is the highest priority in Pneumocystis carinii pneumonia (now Pneumocystis jirovecii pneumonia). This opportunistic infection causes alveolar inflammation, reducing oxygen diffusion across the alveolar-capillary membrane. Hypoxemia results, impairing tissue oxygenation. Prioritizing gas exchange ensures adequate oxygen delivery to vital organs, addressing the life-threatening nature of this respiratory infection.

Choice B reason: Activity intolerance occurs in Pneumocystis pneumonia due to hypoxemia and fatigue from infection. While significant, it is secondary to impaired gas exchange, as oxygen delivery is critical for survival. Addressing hypoxemia through oxygen therapy or ventilation support takes precedence, as it directly impacts the patient’s ability to sustain physical activity.

Choice C reason: Imbalanced nutrition: less than body requirements may occur due to increased metabolic demands or poor appetite in Pneumocystis pneumonia. However, it is not the highest priority, as nutritional deficits are less immediately life-threatening than hypoxemia. Correcting gas exchange ensures oxygenation, which supports metabolic processes before addressing long-term nutritional needs.

Choice D reason: Impaired oral mucous membranes may result from opportunistic infections or treatment side effects in Pneumocystis pneumonia. While uncomfortable, it is not life-threatening compared to impaired gas exchange, which causes hypoxemia and risks organ failure. Addressing respiratory function is critical before managing secondary issues like oral health in this acute infection.

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Which interventions should the nurse implement to prevent a catheter-associated urinary tract infection (CAUTI)? (Select all that apply)

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