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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale:
A WBC count of 5,000/mm³ is within the normal range (4,500 to 11,000 cells/mm³) and is not a priority.
Choice B rationale:
A platelet count of 150,000/mm³ is within the normal range (150,000 to 450,000/mm³) and is not a priority.
Choice C rationale:
A positive Western blot test confirms HIV infection, but it is not a priority in this case.
Choice D rationale:
A CD4-T-cell count of 180 cells/mm³ is below the normal range (500 to 1,500 cells/mm³), indicating severe immune system damage in a client with HIV. This is the nurse’s priority.

A. 8 oz whole milk. B. 8 oz black tea. C. 1.5 oz raisins. D. 1 cup canned black beans.

Correct Answer is D

Explanation

Choice A rationale:
Whole milk is a good source of calcium and vitamin D, but it is not high in iron.
Choice B rationale:
Black tea contains tannins, which can inhibit iron absorption.
Choice C rationale:
Raisins contain some iron, but not as much as other food options.
Choice D rationale:
Black beans are a good source of iron, and consuming them can help increase iron levels in the body, which can alleviate symptoms of iron deficiency anemia.

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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?

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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?