The nurse notes that the client's indwelling urinary catheter bag has had no urine output since being emptied 1 hour ago. What should the nurse's first action be?
Ask the client to bear down as if urinating
Check for kinks in the tubing
Increase fluid intake
Insert a new indwelling urinary catheter
The Correct Answer is B
A. Asking the client to bear down as if urinating: This action is not appropriate in this situation because the lack of urine output may not necessarily be due to the client's inability to void. Checking for other potential issues, such as kinks in the tubing, is more appropriate as a first step.
B. Check for kinks in the tubing: This is the most appropriate first action. Kinks in the tubing can obstruct urine flow from the bladder to the drainage bag, leading to decreased or no urine output. By checking for kinks, the nurse can quickly identify and correct any obstructions, potentially resolving the issue without further intervention.
C. Increasing fluid intake: While maintaining adequate hydration is important for overall urinary function, it is not the most immediate action needed when there is no urine output in the catheter bag. Addressing potential mechanical issues, such as kinks in the tubing, takes precedence.
D. Inserting a new indwelling urinary catheter: Inserting a new catheter should not be the first action taken without investigating other potential causes for the lack of urine output. It is important to troubleshoot and address possible issues with the current catheter and drainage system before considering catheter replacement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
A. Sexually transmitted infections (STIs): Assessing the client's knowledge of STIs is crucial following the initiation of sexual activity to ensure understanding of risks and preventive measures. It enables the nurse to provide education on STI transmission, symptoms, prevention methods (such as condom use), and the importance of regular STI screening.
B. The need for contraception: Assessing the client's understanding of contraception is essential to prevent unintended pregnancies. The nurse can explore the client's knowledge of contraceptive methods, their effectiveness, correct usage, and availability. Providing education on contraceptive options empowers the client to make informed decisions about protecting their sexual health.
C. Facts vs. myths about sex: Assessing the client's understanding of facts and myths surrounding sex helps identify any misconceptions or gaps in knowledge. This allows the nurse to provide accurate information about sexual anatomy, physiology, reproductive health, and healthy sexual practices. Addressing myths promotes sexual health literacy and reduces the risk of misinformation influencing behavior.
D. Hormonally-induced decrease in vaginal lubrication: Assessing hormonal changes affecting vaginal lubrication is less relevant in this context, as it primarily applies to physiological changes in older individuals or those experiencing hormonal fluctuations due to menopause or medical conditions. It is not typically a concern immediately following a first sexual experience in adolescence.
E. Erectile dysfunction: Assessing knowledge of erectile dysfunction is more pertinent in males and is typically not a primary concern immediately following a first sexual experience for a female client. While it is valuable to address sexual health comprehensively, focusing on topics directly relevant to the client's situation is paramount for effective assessment and education.
Correct Answer is B
Explanation
A. Sorry: Expressing regret or remorse for an error is important, but it does not fully encompass the ethical responsibility demonstrated in this scenario. While acknowledging the mistake and feeling sorry is essential, the nurse's primary ethical obligation lies in taking appropriate action to rectify the error and prevent harm to the client.
B. Accountable: Being accountable involves taking responsibility for one's actions, including acknowledging errors, reporting them promptly, and taking corrective measures. In this scenario, the nurse demonstrates accountability by recognizing the administration of a wrong dose of medication and promptly informing the supervisor. Accountability is a fundamental ethical principle in healthcare that promotes transparency, integrity, and patient safety.
C. Altruistic: Altruism involves acting in the best interests of others, often selflessly and without expecting personal gain. While reporting errors and ensuring patient safety can be considered altruistic actions, the primary ethical behavior demonstrated in this scenario is accountability, as the nurse takes responsibility for the medication error.
D. Just: Justice in healthcare refers to fairness, equity, and adherence to ethical principles in the distribution of resources and provision of care. While ensuring justice is an important ethical consideration in healthcare, it is not directly applicable to the nurse's behavior in this scenario. The primary ethical principle demonstrated here is accountability, as the nurse takes responsibility for the medication error and acts to address it appropriately.
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