NCLEX-PN

Category - Basic Care

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A nurse assigned to insert an indwelling urinary catheter in a post-operative client notices that the urine bag of the drainage set is not completely sealed. The most appropriate action of the nurse is to:

Use the drainage set and notify the RN
Dispose of the entire set and use another set
Ask another nurse if the drainage system has ever been touched
Dispose of the entire set in a biohazard bag

Explanation

Answer: B - The best action of the nurse is to dispose of the entire set in the trash can. Although it is untouched, once the seal is broken, it cannot be considered sterile. Disposing the set in a biohazard bag is unnecessary.

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