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 B
Explanation
Choice A reason:
Bowel sounds are an important assessment to determine the return of gastrointestinal function after surgery. However, they are not the immediate priority following a cholecystectomy. The nurse will monitor bowel sounds to assess for ileus or obstruction, but this comes after ensuring that the patient's vital signs are stable.
Choice B reason:
Oxygen saturation is the priority assessment for a client being admitted from the PACU following a cholecystectomy. Ensuring adequate oxygenation is crucial after anesthesia, as respiratory function can be compromised. Monitoring oxygen saturation helps to detect hypoxemia early and prevent respiratory complications.
Choice C reason:
Inspecting the surgical dressing is necessary to check for signs of bleeding or infection at the surgical site. However, this is not the first priority upon admission from the PACU. The nurse will assess the dressing after vital signs and oxygen saturation have been addressed.
Choice D reason:
Temperature is an important vital sign that can indicate infection or other postoperative complications. However, the immediate priority is to ensure the client's airway and breathing are adequate, which includes assessing oxygen saturation before temperature.
Correct Answer is D
Explanation
Choice A reason:
The statement that symptoms can worsen with penile penetration during intercourse is partially correct. While sexual activity may exacerbate feelings of bulging or discomfort associated with uterine prolapse, it does not typically worsen the prolapse itself⁹. Painful intercourse, known as dyspareunia, is a common symptom of pelvic organ prolapse, which includes uterine prolapse.
Choice B reason:
Feeling a sensation of pressure in the pelvis is a classic symptom of uterine prolapse. As the uterus descends into the vaginal canal, it can create a sensation of fullness or pressure that is often noticeable and uncomfortable for the patient.
Choice C reason:
Low back pain is indeed a symptom that can be associated with uterine prolapse. The weakening of pelvic floor muscles and ligaments that leads to prolapse can also contribute to discomfort in the lower back.
Choice D reason:
The presence of feces in the vagina would not be a direct symptom of uterine prolapse. However, a related condition called rectocele, where the rectum bulges into the vagina, could cause such a symptom. This condition is different from uterine prolapse and would require separate management.
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