A nurse is caring for a client who is 5 hours postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?
Adjust the rate of the bladder irrigant.
Irrigate the catheter.
Check the tubing for kinks.
Notify the provider.
The Correct Answer is C
Choice A reason:
Adjusting the rate of the bladder irrigant may be necessary if there is an issue with the flow or the amount of fluid, but it is not the first action to take. The nurse must first ensure that there is no mechanical obstruction causing the lack of drainage.
Choice B reason:
Irrigating the catheter could be the next step if checking the tubing does not resolve the issue. However, it is not the first action to take because if there is a kink in the tubing, irrigation will not be effective and could potentially cause harm.
Choice C reason:
The first action the nurse should take is to check the tubing for kinks because this is a common and easily correctable cause of obstruction in catheter drainage. If the tubing is kinked, straightening it may allow urine to drain properly.
Choice D reason:
Notifying the provider is important if the other interventions do not resolve the issue. However, it is not the first action to take. The nurse should first perform basic troubleshooting steps to identify and correct any simple mechanical issues with the catheter system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Phenytoin is an antiepileptic drug that can be used to treat and prevent seizures. Headache and restlessness could be signs of neurological irritation or an impending seizure, which phenytoin can help to manage. It is important to monitor the client's neurological status closely following hemodialysis, as changes in electrolyte balance can affect neuronal activity.
Choice B reason:
Decreased blood pressure and rapid pulse are not typical indications for administering phenytoin. These symptoms could indicate hypovolemia or other cardiovascular issues that may occur after hemodialysis, which would require different interventions.
Choice C reason:
Muscle cramps and chest heaviness are not indications for phenytoin administration. Muscle cramps can be a common side effect of hemodialysis due to electrolyte shifts, and chest heaviness may indicate cardiovascular strain or other complications.
Choice D reason:
Pain and tingling at the access site are typically related to the vascular access itself and are not treated with phenytoin. These symptoms may require assessment for potential complications such as infection or thrombosis at the access site.
Correct Answer is A
Explanation
Choice A reason: Damage to cartilage and bone can progressively worsen. This is a characteristic of osteoarthritis. The disease is a degenerative joint disease that results in the loss of cartilage, which cushions the ends of bones in joints. As the disease progresses, the cartilage becomes thinner and may wear away entirely, causing the bones to rub against each other. This can result in pain, stiffness, and loss of joint movement.
Choice B reason:
Organ failure in later stages may occur without treatment. This statement is not typically associated with osteoarthritis. While osteoarthritis can significantly impact a person's quality of life, it does not directly cause organ failure. However, it's important to manage osteoarthritis effectively to maintain overall health and prevent secondary complications.
Choice C reason:
Inflammation will resolve over time. This is not typically true for osteoarthritis. While some people with osteoarthritis may experience periods of reduced symptoms, the underlying disease process does not resolve over time. In fact, osteoarthritis usually worsens over time.
Choice D reason:
There will be periods of flare-ups and remission of symptoms. This is true for many people with osteoarthritis. Symptoms can vary and may become more severe during periods of activity or stress on the joint. Conversely, symptoms may decrease during periods of rest or with effective management strategies.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
