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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A Reason: Compressing the nares is not the first action that the nurse should take, as it may increase intracranial pressure and worsen the head injury.

Choice B Reason: Administering decongestant for postnasal drip is not the first action that the nurse should take, as it may mask the signs of cerebrospinal fluid (CSF) leakage and delay diagnosis and treatment.

Choice C Reason: Tilting the head back is not the first action that the nurse should take, as it may cause aspiration of CSF or blood and increase the risk of infection.

Choice D Reason: Collecting the drainage is the first action that the nurse should take, as it helps to identify if the drainage is CSF or nasal secretions, and to monitor the amount and characteristics of the drainage.

A. Managing diarrhea B. Promoting rest and comfort C. Increasing self-esteem D. Promoting self-care and independence

Correct Answer is A

Explanation

Choice A Reason: Managing diarrhea is the priority goal for the client's care, as it helps to prevent dehydration, electrolyte imbalance, malnutrition, and infection.

Choice B Reason: Promoting rest and comfort is an important goal for the client's care, but it is not the priority, as it does not address the underlying cause of the exacerbation.

Choice C Reason: Increasing self-esteem is a long-term goal for the client's care, but it is not the priority, as it does not affect the physical condition of the client.

Choice D Reason: Promoting self-care and independence is a long-term goal for the client's care, but it is not the priority, as it does not affect the acute symptoms of the exacerbation.

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Naxlex Comprehensive Predictor Exams

What should the nurse do first when a client with a head injury begins to have clear drainage from the nose?

Correct Answer is D

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Correct Answer is A

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