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 C
Explanation
The correct answer is: C. Provide the client with an antiemetic 2 hours prior to the chemotherapy.
Choice A reason:
Instructing the client to restrict food intake prior to treatment is not the best approach. While it might reduce nausea temporarily, it can lead to weakness and nutritional deficiencies. Chemotherapy patients need adequate nutrition to maintain their strength and immune function.
Choice B reason:
Encouraging the client to drink a carbonated beverage 1 hour before meals can sometimes help with mild nausea, but it is not as effective as antiemetic medications. Carbonated beverages may provide temporary relief but do not address the underlying cause of chemotherapy-induced nausea.
Choice C reason:
Providing the client with an antiemetic 2 hours prior to chemotherapy is the most effective action. Antiemetics are specifically designed to prevent nausea and vomiting associated with chemotherapy. Administering them before treatment helps to manage symptoms proactively, improving the client's comfort and ability to tolerate chemotherapy.
Choice D reason:
Advising the client to lie down after meals is not recommended as it can worsen nausea and increase the risk of gastroesophageal reflux. It is generally better for clients to remain upright for a period after eating to aid digestion and reduce nausea.
Correct Answer is C
Explanation
Choice A Reason: Cushing's is not an expected health problem in a client with high potassium level, as it causes low potassium level due to excess cortisol and aldosterone production.
Choice B Reason: Diabetes insipidus is not an expected health problem in a client with high potassium level, as it causes low potassium level due to excessive water loss and dilution of blood.
Choice C Reason: Addison's is an expected health problem in a client with high potassium level, as it causes high potassium level due to insufficient cortisol and aldosterone production.
Choice D Reason: Diarrhea is not an expected health problem in a client with high potassium level, as it causes low potassium level due to excessive fluid and electrolyte loss.
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