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. Cardiac enzyme tests, such as troponin and creatine kinase-MB, are used to assess the extent of myocardial damage. Elevated levels of these enzymes indicate that heart muscle cells have been injured or have died.
B. Cardiac enzymes do not localize the MI; imaging studies like echocardiography or coronary angiography are required to identify the specific location of myocardial damage.
C. Pulmonary congestion is assessed using chest X-rays or clinical symptoms, not through cardiac enzyme levels.
D. Cardiac enzyme tests do not provide information about the structure or mobility of heart valves. This information is obtained through echocardiography or other imaging techniques.

A. Differences in upper and lower lung sounds. B. Different apical and radial pulses. C. Differences between oral and axillary temperatures. D. Different blood pressures in the upper limbs.

Correct Answer is B

Explanation

A. Differences in upper and lower lung sounds are not indicative of atrial fibrillation but may suggest other conditions such as fluid accumulation or pneumonia.
B. A difference between apical and radial pulses, known as pulse deficit, can indicate atrial fibrillation due to the irregular and often rapid heartbeat that may not always produce a palpable radial pulse.
C. Differences between oral and axillary temperatures are not relevant to the assessment of atrial fibrillation but could indicate issues with measurement accuracy.
D. Different blood pressures in the upper limbs might suggest vascular issues but are not specific indicators of atrial fibrillation.

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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 teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzyme studies?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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