A nurse is assessing a client who is postoperative following a transurethral resection of the prostate and is receiving continuous bladder irrigation. The client reports bladder spasms, and the nurse notes a scant amount of fluid in the urinary drainage bag. Which of the following actions should the nurse take?

Apply a cold compress to the suprapubic area.

Secure the urinary catheter to the upper left quadrant of the client's abdomen.

Use 0.9% sodium chloride to perform an intermittent bladder irrigation.

Encourage the client to urinate every 2 hr.

Answer and Explanation

The Correct Answer is C

A) This is not a standard intervention for bladder spasms post-TURP.

B)   Securing the urinary catheter to the abdomen does not address the immediate issue of potential catheter blockage.
C)   Performing an intermittent bladder irrigation using sodium chloride is appropriate in this case. This is because bladder spasms and a scant amount of fluid in the urinary drainage bag may indicate a blockage in the catheter. Intermittent bladder irrigation can help to remove any clots or debris that may be causing the blockage.
D)   Encouraging the client to urinate is not applicable as the client cannot urinate normally due to the surgery.

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Correct Answer is B

Explanation

A) Skin breakdown could occur due to the catheter bag lying in bed, but it is not the primary risk associated with the observations noted.
B) A kinked IV tubing can lead to stasis of fluids, which increases the risk of infection. Additionally, if the urinary catheter bag is not positioned below the level of the bladder, urine can reflux back into the bladder, which also increases the risk of infection.
C) Neurogenic bladder is a condition typically associated with nerve damage, not directly related to the position of the catheter bag or kinked tubing.
D) Phlebitis is inflammation of a vein, which would not be directly caused by the issues noted with the urinary catheter.

A. Metoprolol 15 mg IV bolus B. Oxygen at 2 L/min via nasal cannula C. Draw electrolytes along with Hgb and Hct D. Morphine 6 mg IV bolus every 3 hr as needed for pain E. Nitroglycerin 0.5 mg SL now may repeat every 5 min up to 3 doses F. Obtain daily weight G. Atropine 0.5 mg IV bolus every 5 min up to 2 mg if heart rate drops below 60

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"C"}}

Explanation

A) Metoprolol is a beta-blocker that can help reduce heart rate and blood pressure, which is beneficial in cases of chest pain and irregular tachycardia.
B) Oxygen at 2 L/min via nasal cannula is anticipated because the client's oxygen saturation is below normal, indicating they may benefit from supplemental oxygen.
C) Drawing electrolytes along with Hgb and Hct is anticipated as it is important to monitor these levels due to the client's symptoms and history of hypertension and diabetes.
D) Morphine is anticipated because the client reports pain, and morphine can provide pain relief and reduce the workload on the heart.
E) Nitroglycerin is a standard treatment for chest pain due to its vasodilating effects, which can improve blood flow to the heart.
F) Obtaining daily weight is nonessential at this moment because it does not directly address the acute symptoms the client is experiencing.
G) Atropine is contraindicated as the client's heart rate is tachycardic, not bradycardic, and atropine is used to increase heart rate.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?

Correct Answer is B

Explanation

A nurse is reviewing the client’s medical record Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. Potential Prescription: Anticipated Nonessential Contraindicated

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"C"}}

Explanation

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