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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice d. Auscultate lung fields.
Choice A rationale:
Cupping hands and tapping on the patient’s chest is part of the chest percussion technique, which helps to loosen mucus. However, it is not the first step. Before performing any physical intervention, the nurse must assess the patient’s current respiratory status.
Choice B rationale:
Positioning the patient so that the lung area to be drained is above the trachea is part of postural drainage. This step is crucial but should be done after assessing the patient’s lung fields to determine the areas that need drainage.
Choice C rationale:
Providing mouth care is important for overall hygiene and to prevent infection, especially in patients with respiratory conditions. However, it is not directly related to the immediate assessment and intervention for chest physiotherapy.
Choice D rationale:
Auscultating lung fields is the first step because it allows the nurse to assess the patient’s respiratory status and identify areas with abnormal breath sounds, which will guide the subsequent interventions like chest percussion, vibration, and postural drainage. This assessment ensures that the interventions are targeted and effective.
Correct Answer is B
Explanation
Choice A rationale:
Malnutrition is a risk factor for HAIs, but it is not a common cause. Malnutrition weakens the immune system, making it less able to fight off infection. However, malnutrition is not directly responsible for the introduction of pathogens into the body, which is a necessary step for the development of an HAI.
Choice C rationale:
Multiple caregivers can contribute to the spread of pathogens, but it is not a common cause of HAIs. When multiple caregivers are involved in a patient's care, there is a greater chance that one of them may be carrying a pathogen and transmit it to the patient. However, this is not the most common way that HAIs are spread.
Choice D rationale:
Chlorhexidine washes are actually used to prevent HAIs, not cause them. Chlorhexidine is an antiseptic that kills bacteria and other pathogens. It is often used to clean the skin before surgery or other invasive procedures.
Choice B rationale:
Urinary catheterization is a common cause of HAIs. A urinary catheter is a tube that is inserted into the bladder to drain urine. Catheters can introduce bacteria into the bladder, which can lead to urinary tract infections (UTIs). UTIs are the most common type of HAI.
Here are some of the reasons why urinary catheterization is a common cause of HAIs:
Catheters can introduce bacteria into the bladder. The catheter itself can act as a conduit for bacteria to enter the bladder. Bacteria can also enter the bladder around the catheter, where the catheter enters the urethra.
Catheters can irritate the bladder. This can make the bladder more susceptible to infection. Catheters can obstruct the flow of urine. This can allow bacteria to grow in the bladder.
Catheters can be difficult to keep clean. This can increase the risk of bacteria growing on the catheter and being introduced into the bladder.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.