A nurse is caring for a client who is 5 hr 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?

Notify the provider.

Adjust the rate of the bladder irrigant.

Irrigate the catheter.

Check the tubing for kinks.

Answer and Explanation

The Correct Answer is D

A. Notifying the provider is important if initial interventions do not resolve the issue, but it is not the first action to take.
B. Adjusting the rate of the bladder irrigant may help, but first, it is essential to ensure that there is no mechanical obstruction in the tubing.
C. Irrigating the catheter can help clear any blockages, but the first step is to check for any kinks or obvious obstructions in the tubing.
D. Checking the tubing for kinks is the first action as it is a common and easily rectifiable cause of urinary catheter drainage issues. This should be done before other interventions.

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Correct Answer is C

Explanation

A. Although auscultating breath sounds is important, it is not the immediate priority. The client’s symptoms suggest a possible allergic reaction or anaphylaxis.
B. Elevating the head of the bed is important for comfort but is not the first action in the event of a suspected allergic reaction.
C. Stopping the infusion is the first critical step to prevent further exposure to the allergen and reduce the risk of severe reactions.
D. Calling the provider is important but should occur after ensuring the immediate safety of the client by stopping the infusion.

A. Heart rate B. BP C. Weight D. Urine output

Correct Answer is A

Explanation

A. A decrease in heart rate can indicate adequate fluid resuscitation as it suggests improved circulatory status and reduced compensatory tachycardia, which is a response to hypovolemia.
B. An increase, rather than a decrease, in blood pressure would typically indicate improved fluid status and perfusion following adequate fluid resuscitation.
C. Weight changes are not an immediate indicator of fluid resuscitation adequacy. Weight reflects overall fluid balance over a longer period.
D. An increase, not a decrease, in urine output is expected with adequate fluid resuscitation, as improved renal perfusion results in better urine production.

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A nurse is caring for a client who is 5 hr 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

Correct Answer is C

Explanation

A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?

Correct Answer is A

Explanation

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