A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there have not been any urinary output in the last hour. Which of the following actions should the nurse perform first?
Administer antispasmodic medications.
Notify the provider.
Offer oral fluids.
Determine the patency of the tubing.
The Correct Answer is D
Choice A Reason: Administering antispasmodic medications is not the first action that the nurse should perform, as it may not resolve the problem of urinary output or irrigation flow.
Choice B Reason: Notifying the provider is not the first action that the nurse should perform, as it may delay the intervention and worsen the outcome.
Choice C Reason: Offering oral fluids is not the first action that the nurse should perform, as it may increase fluid overload or bladder pressure.
Choice D Reason: Determining the patency of the tubing is the first action that the nurse should perform, as it may identify and correct any obstruction or kinking that prevents urinary output or irrigation flow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: Black cohosh is not an herbal supplement that can help prevent UTIs, but it may be used for menopausal symptoms such as hot flashes, night sweats, or mood swings.
Choice B Reason: Cranberry juice is an herbal supplement that can help prevent UTIs, as it may inhibit bacterial adhesion to the urinary tract and lower urine pH.
Choice C Reason: Saw palmetto is not an herbal supplement that can help prevent UTIs, but it may be used for benign prostatic hyperplasia (BPH) symptoms such as urinary frequency, urgency, or hesitancy.
Choice D Reason: Echinacea is not an herbal supplement that can help prevent UTIs, but it may be used for immune system support or wound healing.
Correct Answer is D
Explanation
Choice A Reason: Calling the RN supervisor is not the priority action for the nurse, as it may delay the intervention and outcome.
Choice B Reason: Completing an incident report is not the priority action for the nurse, as it does not address the immediate problem or prevent further complications.
Choice C Reason: Checking the blood glucose level is not the priority action for the nurse, as it may confirm the error but not correct it.
Choice D Reason: Giving the client 15 to 20 g of carbohydrate is the priority action for the nurse, as it may prevent or treat hypoglycemia, which is a serious complication of insulin overdose.
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