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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason:
While autoimmune disorders are associated with type 1 diabetes, where the immune system attacks the pancreas, they are not typically a direct risk factor for type 2 diabetes. Type 2 diabetes is more closely related to lifestyle factors and insulin resistance.

Choice B reason:
A 40-year-old client with hypoglycemia may be at risk for developing type 2 diabetes. Hypoglycemia can be a sign of pre-diabetes or insulin resistance, where the body's response to insulin is not as effective, leading to fluctuations in blood sugar levels. As individuals age, their risk for type 2 diabetes increases, particularly if they have other risk factors such as a sedentary lifestyle, overweight, or a family history of diabetes.

Choice C reason:
Lack of sleep can contribute to the development of type 2 diabetes by affecting the body's ability to regulate glucose and by increasing insulin resistance. However, without additional risk factors, it is not as strong a predictor of type 2 diabetes as the presence of hypoglycemia or other metabolic conditions.

Choice D reason:
Having never given birth is not a recognized risk factor for type 2 diabetes. While gestational diabetes is a risk factor for developing type 2 diabetes later in life, the absence of pregnancy does not increase the risk.

A. Purulent drainage at the intravenous site access site. B. Redness at the intravenous access site with pain. C. Red streaks on the affected extremity. D. Palpable venous cord in the affected extremity.

Correct Answer is B

Explanation

Choice A reason:
Purulent drainage at the intravenous site access site would indicate a more severe infection, possibly grade 3 or 4 on the Infusion Nurses Society's phlebitis scale. This would be associated with more advanced symptoms such as pus formation, which is not characteristic of grade 1 phlebitis.

Choice B reason:
Redness at the intravenous access site with pain is indicative of grade 1 phlebitis according to the Infusion Nurses Society's phlebitis scale. This grade is characterized by erythema and possible pain at the site of the IV insertion, without more severe symptoms such as swelling or streak formation.

Choice C reason:
Red streaks on the affected extremity suggest a progression of the inflammatory response, potentially indicating a higher grade of phlebitis, such as grade 2 or 3. This symptom suggests that the inflammation is spreading along the vein, which is more serious than grade 1 phlebitis.

Choice D reason:
A palpable venous cord in the affected extremity would also suggest a more severe form of phlebitis, likely grade 3. This occurs when a thrombus forms along with inflammation of the vein, leading to a palpable cord-like structure.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for several clients at a community clinic. Which of the following clients is most at risk for developing type 2 diabetes mellitus?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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