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:
Advising to avoid exercise during flare-ups of fibromyalgia can be beneficial. During flare-ups, symptoms such as muscle pain and fatigue are heightened, and rest may be necessary. However, gentle exercises like stretching or water aerobics might still be recommended to maintain muscle flexibility and strength.
Choice B reason:
Establishing a regular sleep pattern is crucial for managing fibromyalgia. Sleep disturbances are common in fibromyalgia, and poor sleep can exacerbate pain and fatigue. Good sleep hygiene, including a consistent sleep schedule and a comfortable sleep environment, can help improve sleep quality and overall symptom management.
Choice C reason:
While regular exercise is important in managing fibromyalgia, jogging or running may not be suitable for all individuals, especially during periods between flare-ups. Low-impact exercises are generally recommended to reduce stress on the joints and muscles.
Choice D reason:
There is no specific recommendation to increase calcium intake as a self-care strategy for fibromyalgia. While maintaining a balanced diet is important, there is no direct link between calcium intake and fibromyalgia symptom management.
Correct Answer is B
Explanation
Choice A reason:
The statement about using a natural membrane condom rather than a polyurethane condom is incorrect. Natural membrane condoms, such as those made from lambskin, have small pores that can allow viruses to pass through. Therefore, they are not recommended for the prevention of STIs. Polyurethane condoms, on the other hand, do not have these pores and are considered effective in preventing STIs, including HIV.
Choice B reason:
Female condoms, also known as internal condoms, are effective in preventing the transmission of sexually transmitted viruses, including HIV. They act as a barrier to prevent the exchange of bodily fluids during sexual activity, thereby reducing the risk of STI transmission. It's important to include this information in the teaching as it empowers individuals with an additional option for protection.
Choice C reason:
Condoms are designed for single use only. Using a condom more than once greatly increases the risk of condom failure, which can lead to the transmission of STIs or unintended pregnancy. It is crucial to emphasize the importance of using a new condom for each act of sexual intercourse.
Choice D reason:
Oil-based lubricants should not be used with latex condoms as they can weaken the material, leading to condom breakage. Instead, water-based or silicone-based lubricants are recommended as they do not damage the condom and can help prevent breakage.
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