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 C
Explanation
Choice A Rationale: Applying a vest restraint should not be the first action and should only be considered as a last resort after other alternatives have been explored.
Choice B Rationale: Placing the client in bed with two side rails raised may restrict the client's mobility and is not the first choice for managing agitation.
Choice C Rationale: Placing a seat alarm in the client's chair is the first action to take because it allows the nurse to monitor the client's movements and respond promptly to any attempts to get out of the chair while ensuring safety.
Choice D Rationale: Administering lorazepam should not be the first action and should only be considered after non-pharmacological interventions have been attempted
Correct Answer is C
Explanation
Choice A Rationale: Quadriplegia is a type of paralysis that affects all four limbs and the trunk, usually caused by an injury to the cervical spine (C1-C8).
Choice B Rationale: Incomplete loss of function refers to the extent of injury and whether some neurological function remains, not the level of injury.
Choice C Rationale: CA injury refers to cervical spine injury, which is the most common level of spinal cord injury.
Choice D Rationale: Hyperextension, like other mechanisms of injury (such as compression, flexion, or flexion-rotation), can contribute to spinal cord injury but does not define the level of injury.
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