Which nursing diagnosis would be appropriate for a client who has a retention catheter if the drainage bag is found lying on the floor?
1. Risk for Impaired Skin Integrity related to catheter placement
2. Risk for Infection related to improper handling
3. Self-Care Deficit related to presence of a retention catheter
4. Risk for Incontinence related to an obstruction
Correct Answer: 2
Rationale 1: There is a possibility of skin impairment with a catheter, but the emphasis here is on where the drainage bag was found.
Rationale 2: The floor is the dirtiest place, so the drainage device should never be placed on the floor.
Rationale 3: Even though a client has a catheter in place, it does not restrict one from providing self-care. The client may need some assistance.
Rationale 4: The placement of a catheter prevents incontinence; it does not add to it. Patency of the catheter ensures flow, not obstruction.
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