A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate.
The client reports bladder spasms and the nurse observes decreased urinary output.
Which of the following actions should the nurse take?
Remove the indwelling urinary catheter.
Decrease traction on the catheter.
Administer ibuprofen 400 mg for pain relief.
Flush the catheter manually with 0.9% sodium chloride.
The Correct Answer is D
“Flush the catheter manually with 0.9% sodium chloride.” The client is receiving continuous bladder irrigation following a transurethral resection of the prostate and reports bladder spasms and decreased urinary output.
These symptoms may indicate that the catheter is blocked with blood clots.
Flushing the catheter manually with 0.9% sodium chloride can help to remove any blood clots and restore urinary output.
Choice A is not the correct answer because removing the indwelling urinary catheter would not address the underlying issue of blood clots blocking the catheter.
Choice B is not the correct answer because decreasing traction on the catheter would not address the underlying issue of blood clots blocking the catheter.
Choice C is not the correct answer because while ibuprofen may provide some pain relief, it would not address the underlying issue of blood clots blocking the catheter.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is: b. “I apply a lubricating lotion to the cracked areas on the soles of my feet every morning.”
Choice A reason: Elevating the feet for long periods is not generally recommended for clients with Peripheral Arterial Disease (PAD). This is because elevation can decrease arterial blood flow to the feet, which is already compromised in PAD. The goal is to promote blood flow to the extremities, and elevation might work against this, especially if done for extended periods.
Choice B reason: Applying a lubricating lotion to the feet, particularly on the soles where the skin can become very dry and cracked, is beneficial for someone with PAD. It helps to maintain skin integrity and prevent skin breakdown, which can lead to serious complications due to the reduced blood flow and healing capacity in PAD.
Choice C reason: Soaking the feet in hot water is not advisable for individuals with PAD. They may have reduced sensation in their feet due to poor circulation, which increases the risk of burns from hot water. Additionally, prolonged soaking can lead to maceration of the skin, making it more susceptible to injury and infection.
Choice D reason: Using a heating pad, even on a low setting, to keep the feet warm is risky for clients with PAD. Due to decreased sensation from poor circulation, there is a danger of burns because the client may not feel how hot the heating pad is. It’s better to wear warm socks or use room temperature control to keep the feet warm.
Correct Answer is A
Explanation
Oral contraceptive use is a risk factor for the development of DVTs.
Choice B is incorrect because cirrhosis is not a known risk factor for DVTs.
Choice C is incorrect because hypertension is not a known risk factor for DVTs.
Choice D is incorrect because NSAID use is not a known risk factor for DVTs.
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