A nurse is looking after a patient who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation.
The nurse observes that there has been no urinary output in the last hour. What should the nurse do first?

Administer a prescribed analgesic.

Check the patency of the tubing.

Notify the provider.

Offer oral fluids.

Answer and Explanation

The Correct Answer is B

Choice B rationale:

Checking the patency of the tubing is the first and most crucial step in addressing the lack of urinary output in this patient. Here's a detailed explanation of why this is the priority action:

Addresses the Most Likely Cause: Obstruction of the urinary catheter tubing is the most common and easily reversible cause of sudden cessation of urinary output in a patient with a continuous bladder irrigation system.

Prevents Complications: A blocked catheter can lead to a number of serious complications, including: Bladder distention, which can cause pain, discomfort, and potential bladder damage.

Urinary retention, which can increase the risk of urinary tract infections (UTIs) and kidney damage. Hematuria, or blood in the urine, due to clot formation in the bladder or catheter.

Non-Invasive Intervention: Checking the tubing is a simple, non-invasive procedure that can quickly identify and resolve the issue without requiring further interventions or delays in care.

Prioritizes Patient Safety: It's essential to promptly address any potential urinary obstruction to prevent the aforementioned complications and ensure patient safety.

Rationale for Other Choices:

Choice A: Administering a prescribed analgesic:

While pain management is important, it does not directly address the lack of urinary output. Pain medication would be appropriate if pain were assessed to be the cause of the decreased output, but it's not the first priority in this situation.

Choice C: Notifying the provider:

Although the provider should be informed of the situation, checking the tubing for patency is a necessary first step to gather more information and potentially resolve the issue quickly without requiring further intervention.

Choice D: Offering oral fluids:

Increasing fluid intake might be helpful in some cases of decreased urinary output, but it's not the priority action in a patient with a continuous bladder irrigation system and a potential catheter obstruction.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

The correct answer is choiceD.

Choice A rationale:

Assisting the client back into bed is not the initial action.Moving the client without assessing their condition could potentially cause harm.

Choice B rationale:

Notifying the client’s provider is important, but it should be done after assessing the client’s condition to provide accurate information.

Choice C rationale:

Informing the client’s family member is not the immediate priority.The nurse should first ensure the client’s safety and assess their condition.

Choice D rationale:

Obtaining the client’s vital signs is the initial action.This helps assess the client’s current condition and determine if there are any immediate medical needs.

A. “I will avoid crossing my legs at the knees.” B. “I will not go barefoot.” C. “I will use a thermometer to check the temperature of my bath water.” D. “I will wear stockings with elastic tops.”

Correct Answer is C

Explanation

Choice A rationale:

Avoiding crossing legs at the knees is a correct practice for people with PVD. It helps to prevent constriction of blood flow in the legs. When legs are crossed, pressure is applied to the veins in the lower leg, which can impede blood flow. This can lead to several problems, including:

Increased risk of blood clots Worsening of swelling in the legs Increased pain and discomfort Potential skin damage

Reinforcing this practice with the client is important.

Choice B rationale:

Not going barefoot is also a correct practice for people with PVD. It helps to protect the feet from injuries and infections. People with PVD may have reduced sensation in their feet, making them more susceptible to injuries they may not notice. Additionally, PVD can impair wound healing, so even minor injuries can become serious problems.

Reinforcing this practice with the client is important.

Choice C rationale:

Using a thermometer to check bath water temperature is not directly relevant to PVD management. While it's generally a good safety practice to avoid excessively hot water, which can burn the skin, it's not specifically related to the blood flow issues associated with PVD.

This statement indicates a need for further teaching to focus on PVD-specific self-care measures.

Choice D rationale:

Wearing stockings with elastic tops is generally recommended for people with PVD. These stockings, often referred to as compression stockings, help to improve blood flow in the legs by applying gentle pressure. This can help to reduce swelling, pain, and the risk of blood clots.

Reinforcing this practice with the client is important.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is looking after a patient who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation.The nurse observes that there has been no urinary output in the last hour. What should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse enters a client’s room to answer the call light and finds the client on the bathroom floor. What should be the nurse’s initial action?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). Which of the following statements by the client indicates a need for further teaching?

Correct Answer is C

Explanation

A male patient informs the nurse that he prefers not to have female assistive personnel (AP) involved in his care. Which response should the nurse provide?

A nurse is caring for a patient on the third day following abdominal surgery. The nurse notes the absence of bowel sounds, abdominal distention, and the patient has not passed any flatus. Which postoperative complication is the patient likely experiencing?

A 79-year-old patient reports a pain level of 3 out of 10 and states, “Don’t worry, this is just part of getting old.” What is the best response?

A nurse is providing care to a group of patients in an adult medical-surgical unit. Which patient should the nurse identify as having the highest risk for aspiration?

A nurse is observing the IV catheter insertion site of a client who is receiving continuous IV therapy.Which of the following manifestations should the nurse identify as an indication that the client has developed phlebitis?

Anaphylactic shock is a subgroup of which type of shock?

A nurse is caring for a patient who is postoperative and receiving fentanyl via patient-controlled analgesia. The patient has a prescription for naloxone. What is the purpose of naloxone?

A nurse is monitoring a patient who is receiving a blood transfusion. Which of the following symptoms should the nurse report to the charge nurse as a sign of an allergic blood transfusion reaction?

A nurse is looking after a patient who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation.
The nurse observes that there has been no urinary output in the last hour. What should the nurse do first?