A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following actions should the nurse take?
Irrigate the catheter with sterile water
Clamp the drainage catheter during ambulation
Report viscous drainage with clots to the provider
Remove the catheter if the client feels a strong urge to urinate
The Correct Answer is C
Choice A reason: Irrigating the catheter with sterile water is an incorrect action, because the catheter should be irrigated with sterile normal saline (0.9% sodium chloride) to prevent hemolysis of the red blood cells.
Choice B reason: Clamping the drainage catheter during ambulation is an incorrect action, because the catheter should be kept patent and unclamped at all times to prevent obstruction and infection.
Choice C reason: Reporting viscous drainage with clots to the provider is a correct action, because it indicates that the irrigation is not effective and the client may need manual irrigation or surgical intervention.
Choice D reason: Removing the catheter if the client feels a strong urge to urinate is an incorrect action, because the catheter should be left in place until the provider orders its removal. The client may feel a sensation of bladder fullness or spasms due to the irrigation fluid, which can be relieved by medication or adjustment of the flow rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is a dangerous action, because recapping the needle on the syringe can increase the risk of needlestick injuries and bloodborne infections.
Choice B reason: This is an unnecessary action, because the client may be able to self-administer insulin injections with proper education and supervision.
Choice C reason: This is an inappropriate action, because the syringe should not be disposed of in the bathroom trash can, which is not a safe or sanitary place for sharps waste.
Choice D reason: This is the correct action, because placing the syringe in a puncture-proof disposal container can prevent accidental injuries and infections, and comply with the local regulations for sharps disposal.
Correct Answer is ["A","C","D"]
Explanation
The correct answer is A, C, D
Choice A reason: Allopurinol is a medication that helps reduce the production of uric acid, which is beneficial for patients with gout and urolithiasis to prevent the formation of uric acid stones.
Choice B reason: While regular exercise is generally beneficial for overall health, it does not have a direct impact on the prevention of uric acid stone formation. Therefore, it is not a specific recommendation for preventing uric acid stone.
Choice C reason: Foods high in purines can increase uric acid levels in the body, leading to the formation of uric acid stones. Limiting the intake of such foods is a key step in preventing uric acid stones.
Choice D reason: Adequate fluid intake is crucial as it helps to dilute the urine, which can prevent the formation of uric acid stones by reducing the concentration of uric acid in the urine.
Choice E reason: Contrary to the statement, lemonade may actually be beneficial in preventing uric acid stones because it contains citrate, which can help prevent stone formation. Citrate can bind to calcium and prevent stone formation, and it also makes the urine less acidic, which can help prevent the formation of uric acid stones.
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