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?
Irrigate the catheter.
Notify the provider.
Check the tubing for kinks.
Adjust the rate of the bladder irrigant.
The Correct Answer is C
Choice A rationale:
Irrigating the catheter may be necessary, but it is not the first action to take.
Choice B rationale:
Notifying the provider is important, but there are actions the nurse can take first.
Choice C rationale:
Checking the tubing for kinks is the first action because it is a simple and non-invasive intervention.
Choice D rationale:
Adjusting the rate of the bladder irrigant may be necessary, but it is not the first action to take.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Checking the catheter tubing for kinks or twisting helps to maintain a patent urinary drainage system, preventing urinary stasis that can lead to infection.
Choice B rationale:
Irrigating the catheter once each shift is not recommended as it can introduce bacteria into the bladder.
Choice C rationale:
Cleaning the perineal area with an antiseptic solution daily can disrupt the normal flora and cause irritation, potentially leading to infection.
Choice D rationale:
Replacing the catheter every 3 days is not recommended as it can increase the risk of urinary tract infection.
Correct Answer is A
Explanation
Choice A rationale:
Restlessness is a common early sign of increased intracranial pressure (ICP). It can be caused by the brain’s response to the pressure, leading to agitation and restlessness.
Choice B rationale:
Tachycardia, or a rapid heart rate, is not typically a sign of increased ICP. It can be a response to other factors such as pain, anxiety, or certain medications.
Choice C rationale:
Hypotension, or low blood pressure, is not typically a sign of increased ICP. In fact, hypertension, or high blood pressure, is more commonly associated with increased ICP2.
Choice D rationale:
Amnesia, or memory loss, is not typically a sign of increased ICP. It can be a result of the brain injury itself, but it is not a direct indicator of increased ICP2.
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