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 D
Explanation
Choice A rationale:
Cardiac enzymes do not identify the location of the MI, they are biomarkers that indicate heart muscle injury.
Choice B rationale:
Cardiac enzyme tests do not provide information about the heart’s structure or the mobility of the heart valves. That’s typically assessed using imaging studies like an echocardiogram.
Choice C rationale:
Cardiac enzymes do not assist in diagnosing the presence of pulmonary congestion. They are specific to heart muscle damage.
Choice D rationale:
Cardiac enzymes, such as troponin and creatine kinase, rise when there is damage to the heart muscle, such as in an MI. Therefore, these tests help determine the degree of damage to the heart tissues.
Correct Answer is D
Explanation
Choice A rationale:
Aspirin is not typically recommended for gout due to its potential to elevate uric acid levels.
Choice B rationale:
A high-purine diet can exacerbate gout symptoms, so this statement is incorrect.
Choice C rationale:
Limiting fluid intake can lead to dehydration, which can trigger a gout attack.
Choice D rationale:
Alcohol, especially beer, can increase uric acid levels and trigger gout attacks, so limiting alcohol intake is recommended.
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