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 A

Explanation

A. Airway obstruction is the priority because burns to the head, neck, and chest can compromise the airway due to swelling, soot, and edema. Immediate assessment and intervention are critical to ensure the airway remains patent and to prevent respiratory distress.

B. While infection is a significant risk in burn patients, addressing airway concerns takes precedence to prevent immediate life-threatening complications.

C. Paralytic ileus is a concern in burn patients but is less immediate compared to the risk of airway obstruction.

D. Fluid imbalance is crucial in burn management, but ensuring a clear airway is the immediate priority to prevent severe complications such as asphyxia.

A. side effects of immunosuppressants. B. constipation. C. fatigue. D. bleeding.

Correct Answer is D

Explanation

A. While monitoring for side effects of immunosuppressants is important, the immediate priority is managing the risk associated with the primary condition.
B. Constipation is a common issue but is not the primary concern in the context of ITP.
C. Fatigue may be related to anemia or other factors but is secondary to the risk of bleeding in ITP.
D. Bleeding is the priority concern in ITP due to the low platelet count, which increases the risk of hemorrhage and requires careful monitoring and intervention.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

Correct Answer is A

Explanation

A nurse is assigned to care for a client diagnosed with autoimmune or idiopathic thrombocytopenic purpura (ITP). When reviewing the client's plan of care prior to caring for the client, the nurse should recognize that the priority concern in caring for the client is to monitor for

Correct Answer is D

Explanation

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