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 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.
Correct Answer is C
Explanation
Choice A Rationale: Oral care is important for overall hygiene but may not take precedence over other critical aspects of care for a client with a spinal cord injury.
Choice B Rationale: Offering the client to discuss their feelings is important for emotional support but may not be the highest priority.
Choice C Rationale: Diet modifications are a high priority because they are essential for addressing the client's nutritional needs and preventing complications related to the spinal cord injury, such as pressure ulcers and infections.
Choice D Rationale: The application of compression stockings may have a role in the care plan but is not typically the highest priority for a client with a spinal cord injury.
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