A nurse enters a client’s room at the beginning of a shift. Which of the following findings requires intervention by the nurse?
A A capped bottle of sterile water that was opened 36 hours ago
B A urinary catheter drainage bag that is hanging on the lower portion of the bed frame
C A peripheral IV catheter that was inserted 2 days ago
D A wound dressing that requires frequent changes and is secured using Montgomery straps
The correct answer and explanation is :
Correct Answer: A. A capped bottle of sterile water that was opened 36 hours ago
Explanation:
Sterile water is commonly used in various nursing procedures, including humidification of oxygen, irrigation, and suctioning. However, once a bottle of sterile water is opened, it is no longer guaranteed to remain sterile indefinitely—even if it is capped. Guidelines typically recommend discarding sterile water bottles within 24 hours of opening, unless the manufacturer specifies otherwise. This helps minimize the risk of contamination and subsequent infection, especially in procedures involving mucous membranes, surgical sites, or open wounds. Therefore, a bottle that was opened 36 hours ago exceeds the safe usage window and should be discarded, making this a priority for nursing intervention.
Let’s examine the other options:
B. A urinary catheter drainage bag that is hanging on the lower portion of the bed frame
This is appropriate. To prevent backflow of urine (which can cause urinary tract infections), the drainage bag should be positioned below the level of the bladder, and securing it to the lower portion of the bed frame (not side rails) is correct. No intervention is needed here.
C. A peripheral IV catheter that was inserted 2 days ago
Peripheral IV sites can generally remain in place for 72–96 hours (3–4 days) unless signs of infection, infiltration, or phlebitis appear. Since this catheter was inserted only 2 days ago, it is still within the acceptable time frame, and no intervention is immediately required.
D. A wound dressing that requires frequent changes and is secured using Montgomery straps
Montgomery straps are an accepted method for securing dressings that need frequent changes. They help reduce skin irritation caused by repeated tape removal. Their use indicates good practice, not a problem.
Summary:
Option A presents a potential infection risk due to prolonged exposure of sterile water beyond recommended time limits. This requires prompt nursing intervention to ensure patient safety and uphold infection control standards.