79.When assessing a client with an indwelling urinary catheter, which
observation requires the most immediate intervention by the nurse?
A. The drainage tubing is secured over the siderail.
B. The clamp on the urinary drainage bag is open.
C. There are no dependent loops in the drainage tubing.
D. The urinary drainage bag is attached to the bed frame.
Maintaining a closed urinary drainage system is important to prevent
infection, so the most immediate priority is to close the clamp (B) to
reduce the risk for ascending microorganisms. If the drainage tubing is
secured over the siderail (A), urine will not be able to flow out of the
bladder, so the nurse should next reposition the tubing. (C and D)
indicate correct care of the urinary drainage system, so
documentation of an intact system is the last intervention needed.
Correct Answer: B
observation requires the most immediate intervention by the nurse?
A. The drainage tubing is secured over the siderail.
B. The clamp on the urinary drainage bag is open.
C. There are no dependent loops in the drainage tubing.
D. The urinary drainage bag is attached to the bed frame.
Maintaining a closed urinary drainage system is important to prevent
infection, so the most immediate priority is to close the clamp (B) to
reduce the risk for ascending microorganisms. If the drainage tubing is
secured over the siderail (A), urine will not be able to flow out of the
bladder, so the nurse should next reposition the tubing. (C and D)
indicate correct care of the urinary drainage system, so
documentation of an intact system is the last intervention needed.
Correct Answer: B
