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 B

Explanation

Choice A rationale:
Flexing her ankles is a safe action that promotes blood flow and prevents clot formation.
Choice B rationale:
Massaging her legs can dislodge a clot if one has formed, leading to a VTE.
Choice C rationale:
Elevating her feet improves venous return, reducing the risk of VTE.
Choice D rationale:
Ambulating soon after surgery promotes blood flow and prevents clot formation.

A. Obtain a sputum culture. B. Position head of bed at 10 degrees. C. Cough and deep breathe every 8 hr. D. Encourage fluid intake of 1500 mL/day.

Correct Answer is A

Explanation

Choice A rationale:
Obtaining a sputum culture helps identify the causative organism and guide treatment.
Choice B rationale:
Positioning the head of bed at 10 degrees is not beneficial for pneumonia patients.
Choice C rationale:
Coughing and deep breathing every 8 hours is not frequent enough for pneumonia patients.
Choice D rationale:
Encouraging fluid intake of 1500 mL/day is not sufficient for pneumonia patients.

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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

A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions?

Correct Answer is B

Explanation

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Correct Answer is A

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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?