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. If I feel nervous or have tremors, I should only take half the dose. B. I can expect diarrhea, insomnia, and excessive sweating. C. I need to call my healthcare provider if my heart rate becomes fast. D. I should take the medication in the evening.

Correct Answer is C

Explanation

Choice A Reason: If I feel nervous or have tremors, I should not only take half the dose, but I should contact my healthcare provider, as these may indicate signs of overdose or hyperthyroidism.

Choice B Reason: I cannot expect diarrhea, insomnia, and excessive sweating, but these are possible side effects of overdose or hyperthyroidism.

Choice C Reason: I need to call my healthcare provider if my heart rate becomes fast, as this may indicate a serious adverse reaction or overdose of levothyroxine sodium.

Choice D Reason: I should not take the medication in the evening, but in the morning on an empty stomach at least 30 minutes before breakfast, as this ensures better absorption and prevents insomnia.

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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

Explanation

A nurse reinforces instructions to a client with hypothyroidism about the dosage, method of administration, and side effects of levothyroxine sodium. Which statement by the client indicates an understanding of the nurse's instructions?

Correct Answer is C

Explanation

A client has been diagnosed with hypothyroidism. What information should the nurse obtain when conducting a focused assessment? Select all that apply.

Which of the following would be the most appropriate nursing diagnosis for a client admitted with Addison's disease?

A nurse is reinforcing teaching about an endoscopy with a client who has dysphagia. Which of the following statements should the nurse include in the teaching?

A nurse is reinforcing teaching about TNM staging with a client who has cancer. Which of the following information should the nurse include in the teaching?

A home health nurse reinforces instructions to a client who is taking allopurinol for the treatment of gout. The nurse provides which client instructions?

A nurse is contributing to the plan of care for a client who has urolithiasis. Which of the following interventions should the nurse include in the plan?

A nurse is planning to reinforce teaching with a client who has hemorrhoids. Which of the following information should the nurse plan to include in the instructions?

A nurse is assisting with the care of a client who is 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take?