A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection?
Change the catheter once each shift.
Check the catheter tubing for kinks or twisting.
Replace the catheter every 3 days.
Clean the perineal area with an antiseptic solution once daily.
The Correct Answer is B
Rationale:
A. Changing the catheter once each shift is unnecessary and can increase the risk of infection. Catheters should be replaced only when clinically indicated.
B. Checking the catheter tubing for kinks or twisting is essential to ensure proper drainage and reduce the risk of infection. This action promotes unobstructed urine flow, which is critical for infection prevention.
C. Replacing the catheter every 3 days is not a standard practice; catheters should be changed based on clinical need rather than a set schedule. This could unnecessarily increase the risk of infection.
D. While cleaning the perineal area is important, using an antiseptic solution daily may cause irritation and disrupt the normal flora of the area. Routine cleaning with mild soap and water is typically recommended instead.
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Correct Answer is B
Explanation
Rationale:
A. Being male is not a significant risk factor for developing pressure ulcers. Pressure ulcers are more related to factors like immobility, nutritional status, and circulation.
B. Immobility is a major risk factor for pressure ulcer development. Clients who are immobile or confined to bed, especially for prolonged periods, are at higher risk due to continuous pressure on certain body areas, leading to skin breakdown.
C. Adequate hydration helps maintain skin integrity and is not a risk factor for pressure ulcers. Dehydration, rather than adequate hydration, can contribute to skin breakdown.
D. Anemia can impact tissue oxygenation, but immobility is a more direct risk factor for pressure ulcer development. Although anemia can slow healing, immobility leads to constant pressure on the skin, causing tissue breakdown and ulceration.
Correct Answer is ["A","B","E"]
Explanation
Rationale:
A. The opening of the pouch should be cut about 1/8 of an inch larger than the stoma to ensure a proper fit without restricting blood flow or irritating the stoma.
B. Placing a gauze over the stoma during a pouch change helps to absorb any discharge and keep the area clean while preparing the new appliance.
C. Povidone-iodine should not be used to clean around the stoma, as it can irritate the skin. The skin should be cleaned with mild soap and water or a recommended stoma cleanser.
D. A stoma that turns purple-blue is a sign of impaired blood flow and requires immediate medical attention. A healthy stoma should appear pink or red and moist.
E. The ostomy pouch should be emptied when it is about one-third full to prevent leakage, odor, and unnecessary pressure on the stoma.