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. While rest might help, it does not address the underlying issues of nausea and weakness that could be related to digoxin toxicity or another urgent condition.
B. A dietitian consult is not immediate or necessary at this moment; the priority is to assess the client's current symptoms.
C. Checking the client’s vital signs is the first action to identify if there are any abnormal findings such as bradycardia or other signs of digoxin toxicity, which could be causing the symptoms.
D. Requesting an antiemetic might be appropriate if nausea is confirmed, but the priority is to first assess the client’s vital signs to rule out serious issues.

A. Hold the client's arms and legs from moving. B. Place the client back in bed. C. Insert a tongue blade in the client's mouth. D. Place the client on his side.

Correct Answer is D

Explanation

A. Holding the client's arms and legs can cause injury and does not help in managing the seizure. The focus should be on protecting the client from harm.
B. Moving the client back to bed during a seizure can be dangerous and increase the risk of injury. It's best to manage the seizure where the client is.
C. Inserting a tongue blade or any object into the client's mouth can cause injury to the teeth or oral cavity and is not recommended during a seizure.
D. Placing the client on his side helps maintain an open airway and prevents aspiration, which is crucial during a seizure to ensure the client’s safety.

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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 is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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