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. A self-report pain rating scale is not effective for clients with expressive aphasia as they may have difficulty communicating verbally. Alternative methods are needed to assess pain in these clients.

B. Scheduled treatments and client illness are not direct methods for assessing pain levels. They provide context but do not directly measure pain.

C. Behavioral indicators and effect are crucial for assessing pain in clients with expressive aphasia. Observing changes in behavior and facial expressions can help identify discomfort when verbal communication is not possible.

D. Pulse and blood pressure findings can be influenced by pain but are not specific indicators of pain level. Behavioral observations are more direct and reliable in clients with communication difficulties.

A. Vitamin C B. Oxalates C. Fiber D. Vitamin A

Correct Answer is A

Explanation

A. Vitamin C enhances the absorption of non-heme iron from plant-based sources by converting iron to a more absorbable form. Including vitamin C-rich foods with iron-rich meals can improve iron uptake.
B. Oxalates, found in foods like spinach and rhubarb, can inhibit iron absorption by binding to iron and reducing its availability.
C. Fiber, while beneficial for digestive health, does not enhance iron absorption and can, in some cases, inhibit it by binding to minerals.
D. Vitamin A does not have a direct role in the absorption of iron, though it is essential for overall health.

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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

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