A nurse caring for a client with a new spinal cord injury notices that the indwelling urinary catheter has stopped flowing. What is the nurses best first action?
Notify the physician
Check the tubing
Remove the indwelling catheter
Replace the indwelling catheter
The Correct Answer is B
Choice A Rationale: Notifying the physician may be necessary if troubleshooting the issue does not resolve the problem, but it is not the initial step.
Choice B Rationale: The nurse should first check the tubing of the indwelling urinary catheter for any kinks, twists, or obstructions that might prevent the urine flow. This is a simple and non-invasive intervention that can resolve the problem quickly and easily.
Choice C Rationale: Removing the indwelling catheter is not advisable without proper assessment and intervention, as it can lead to complications.
Choice D Rationale: Replacing the indwelling catheter is not the first step and should only be done if the problem cannot be resolved through assessment and interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Rationale: Draining the bladder with a clean intermittent catheter at appropriate intervals is an essential part of managing urinary system complications in clients with spinal cord injury to prevent urinary retention and complications.
Choice B Rationale: Decreasing fluid intake is not typically recommended for individuals with spinal cord injuries, as adequate hydration is important for overall health.
Choice C Rationale: Observing the urine for a foul odor is relevant to monitor for urinary tract infections, but it is not a preventive measure.
Choice D Rationale: Keeping an indwelling catheter in place at all times is not typically recommended due to the increased risk of urinary tract infections and other complications. Clean intermittent catheterization is often preferred.
Correct Answer is D
Explanation
Choice A Rationale: Eating only cold foods is not a common recommendation for preventing trigeminal neuralgia flare-ups.
Choice B Rationale: Massaging the affected side multiple times a day is not typically recommended and may exacerbate symptoms.
Choice C Rationale: Applying heat or cold to alleviate symptoms can vary depending on individual preferences and is not a primary preventive measure for triggering an acute onset.
Choice D Rationale: Using a soft bristle toothbrush and warmed mouthwash is a recommended preventive measure to avoid triggering acute episodes of trigeminal neuralgia. It helps reduce irritation to the affected nerves.
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