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:
Cataract extraction is a minor procedure and does not pose a significant risk for DVT.
Choice B rationale:
Myringotomy, a procedure to drain fluid from the middle ear, also does not significantly increase DVT risk.
Choice C rationale:
Laparoscopic appendectomy, while more invasive, still carries a lower DVT risk compared to major orthopedic surgeries.
Choice D rationale:
Hip arthroplasty, a major orthopedic surgery, poses a high risk for DVT due to prolonged immobility and venous stasis.
Correct Answer is A
Explanation
Choice A rationale:
Hemoglobin of 10 g/dL and hematocrit of 30% are lower than the normal ranges (Hemoglobin: 13.5-17.5 g/dL for men, 12.0-15.5 g/dL for women; Hematocrit: 38.8-50.0% for men, 34.9-44.5% for women). This can lead to cellular hypoxia as there are fewer red blood cells to carry oxygen.
Choice B rationale:
These lab values do not directly indicate a risk for prolonged bleeding.
Choice C rationale:
These lab values do not directly indicate a risk for fluid retention.
Choice D rationale:
While severe anemia can affect the immune response, these values do not directly indicate impaired immunity.
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