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 B
Explanation
Choice A Rationale: hyperextension is when the neck is bent backward beyond its normal range of motion. This can happen in a rear-end collision or a fall on the back of the head.
Choice B Rationale: A spinal cord injury occurs when there is damage to the spinal cord or the surrounding structures, such as the vertebrae, ligaments, or discs. The most common cause of spinal cord injury is trauma, which can result from direct impact, penetration, or excessive force on the spine. Diving into shallow water can cause compression of the spine, which means that the vertebrae are pushed together and squeeze the spinal cord. This can damage the nerve fibers and disrupt the communicationbetween the brain and the body. Compression injuries can affect any part of the spine, but are more common in the cervical and thoracic regions.
Choice C Rationale: flexion-rotation is when the neck is bent and twisted at the same time. This can happen in a sports injury or a violent assault.
Choice D Rationale: This is when the neck is bent forward beyond its normal range of motion. This can cause the posterior part of the vertebral column to compress and fracture, while the anterior part of the spinal cord is stretched and injured. This can happen in a head-on collision or a fall on the face. A flexion-rotation is when the neck is bent and twisted at the same time.
Correct Answer is C
Explanation
Choice A Rationale: Repositioning may be important for preventing complications, but it does not explain the pain described by the client.
Choice B Rationale: A continual inflammatory process is not typically the cause of the pain described by the client with a spinal cord injury.
Choice C Rationale: Nerve damage in the spinal cord is a common cause of neuropathic pain with these characteristics.
Choice D Rationale: Telling the client that the pain will go away in 2 weeks without further assessment or explanation is not accurate and may raise unrealistic expectations.
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