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 D

Explanation

A. Decreased specific gravity is not typical of right-sided heart failure. Increased specific gravity is often associated with fluid retention.
B. PAWP is more relevant for left-sided heart failure; right-sided heart failure would typically not show an increase in PAWP.
C. BNP levels usually increase in heart failure, including right-sided heart failure, not decrease.
D. Elevated CVP and jugular vein distention are classic signs of right-sided heart failure due to increased venous pressure and fluid overload.

A. Apply petroleum jelly to the client's lips after oral care. B. Use a stiff toothbrush to clean the client's teeth. C. Use the thumb and index finger to keep the client's mouth open. D. Turn the client on his side before starting oral care.

Correct Answer is D

Explanation

A. Applying petroleum jelly to the client's lips can lead to aspiration if the client is unable to swallow properly. It is not recommended as a routine practice for oral care.

B. A stiff toothbrush can cause gum damage or discomfort. A soft toothbrush is preferred for oral care, especially for clients who may have sensitive or fragile gums.

C. Using the thumb and index finger to keep the client's mouth open is not safe or effective. It can cause discomfort or injury. Using appropriate tools, like a mouth prop or suction if necessary, is recommended.

D. Turning the client on their side before starting oral care is the correct action. This position helps prevent aspiration of secretions or water during oral care, reducing the risk of choking or aspiration pneumonia.

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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 a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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