Nursing Fundamentals Course (71-75)

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71. The nurse inserts an indwelling urinary catheter into a male client. As the catheter moves into the bladder, urine begins to flow into the tubing. Which should the nurse implement next?

a) inflate the balloon with water
b) insert the catheter 2.5 to 5 cm
c) measure the initial urine output
d) secure the catheter to the client

72. A nurse is collecting a sputum specimen for culture and sensitivity testing from a client who has a productive cough. The nurse plans to implement which intervention to obtain the specimen?

a) ask the client to obtain the specimen after breakfast
b) use a sterile plastic container for obtaining the specimen
c) provide tissues for expectoration and obtaining the specimen
d) ask the client to expectorate a small amount of sputum into the emesis basin

73. A client who is 40 years old has a severe mental impairment and is scheduled fro gallbladder surgery. Which should the nurse implement about the informed consent first to facilitate the scheduled surgery?

a) check for the identity of the client's legal guardian
b) inform the legal guardian about advanced directives
c) arrange fro the surgeon to provide informed consent
d) ensure that the legal guardian signed the informed consent

74. Which action does the nurse implement to obtain a urine specimen for a urinalysis from a female client with an indwelling urinary catheter?

a) detach the tubing of the drainage bag
b) use a sterile container for the specimen
c) cleanse the perineum from front to back
d) aspirate the urine from the drainage bag port

75. The nurse has given a subcutaneous injection to a client with acquired immunodeficiency syndrome (AIDS). The nurse disposes of the used needle and syringe by:

a) breaking the needle before discarding it
b) recapping the needle and discarding the syringe in a disposal unit
c) placing the uncapped needle and syringe in a labeled cardboard box
d) placing the uncapped needle and syringe in labeled, rigid plastic container







Nursing Fundamentals Course
Answers and Rationale

71) B

- The catheter's balloon is behind the opening at the insertion tip, so the nurse inserts the catheter 2.5 to 5 cm further after urine begins to flow in order to provide sufficient space to inflate the balloon. After the nurse secures the catheter to the client's leg, the nurse measures the initial urine output.

72) B

- Sputum specimens for culture and sensitivity testing need to be obtained using sterile techniques, because the test is done to determine the presence of organisms. If the procedure for obtaining the specimen is not sterile, then the specimen would be contaminated and the results of the test would be invalid. A first morning specimen is preferred because it represents overnight secretions of the tracheobronchial tree.

73) A

- The client is not competent to sign an informed consent, so the nurse verifies the identity of the client's legal guardian to fulfill part of the nurse's duty in informed consent. This helps avoid improperly signed documents and to direct the surgeon to the legal representatives of the client's interests. Most states require client notification of advanced directives at admission.

74) D

- A specimen for urinalysis does not need to be sterile; however, the system must remain sterile to reduce the risk of infection. Therefore, the nurse obtains the specimen using sterile technique and obtains a fresh specimen by aspirating urine from the drainage bag port after sanitizing the port and inserting a sterile needle. The nurse avoids breaking the integrity of the urinary collection system to prevent contamination. The nurse also avoids taking urine from the urinary drainage bag because the urine is less likely to reflect the current client status and because urine undergoes chemical changes and particulate matter settles over time. A sterile container is unnecessary for a urinalysis, and because the client has an indwelling catheter, perineal cleansing before obtaining a urine specimen is unnecessary.

75) D

- Standard precautions include specific guidelines for handling of needles. Needles should not be recapped, bent, broken, or cut after use. They should be disposed of in a labeled, impermeable container specific for this purpose. Needles should not be discarded in cardboard boxes, because these types of boxes are not impervious. Needles should never be left lying around after use.


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Nursing Fundamentals Course (1-5)

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Nursing Fundamentals Course (76-80)