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 A
Explanation
Choice A Reason: Checking blood sugar then eating breakfast prior to injecting insulin indicates that additional teaching is necessary, as it may cause hyperglycemia or hypoglycemia depending on the type and timing of insulin. The client should inject insulin before eating breakfast according to their blood sugar level and carbohydrate intake.
Choice B Reason: Rotating sites from arms, legs, and abdomen indicates that no additional teaching is necessary, as it helps to prevent lipodystrophy and ensure consistent absorption of insulin.
Choice C Reason: Ensuring the use of insulin syringe with units indicates that no additional teaching is necessary, as it helps to prevent dosing errors and ensure accurate administration of insulin.
Choice D Reason: Activating the safety lock on the syringe before disposing in a sharps container indicates that no additional teaching is necessary, as it helps to prevent needlestick injuries and infection transmission.
Correct Answer is B
Explanation
Choice A Reason: Telling the client to expect a decrease in urine output is not an appropriate intervention for a client who has urolithiasis, as it may indicate dehydration, obstruction, or infection.
Choice B Reason: Encouraging the client to drink 3 L of fluids per day is an appropriate intervention for a client who has urolithiasis, as it helps to flush out stones, prevent new stone formation, and reduce urinary concentration.
Choice C Reason: Providing the client with a high protein diet is not an appropriate intervention for a client who has urolithiasis, as it may increase uric acid and calcium excretion and promote stone formation.
Choice D Reason: Maintaining the client on bed rest is not an appropriate intervention for a client who has urolithiasis, as it may decrease renal perfusion and increase urinary stasis.
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