The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 8-hour shift. Which intervention should the nurse implement first?
Review the intake and output record.
Give the client 8 ounces of water to drink.
Notify the healthcare provider.
Check the drainage tubing for a kink.
The Correct Answer is D
A. Reviewing the intake and output record is important for overall assessment but does not address the immediate issue of low urine output.
B. Giving the client water might be appropriate if the low output is related to dehydration, but the first step is to investigate possible mechanical issues with the catheter.
C. Notifying the healthcare provider might be necessary if there is a persistent problem, but it is important first to identify and address any immediate issues with the catheter.
D. Checking the drainage tubing for a kink is the first step to ensure that the catheter is functioning properly. Mechanical obstruction can cause reduced urine output and should be assessed before taking further actions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Paper masks and gowns used for isolation precautions should be placed in a designated biohazard bag before removal from the room. These items are considered contaminated and must be disposed of according to infection control protocols.
B. A sputum specimen should be placed in a sealed, labeled container before being transported to the lab, not in a biohazard bag for disposal.
C. The nurse's stethoscope should be disinfected but does not need to be disposed of unless it is single-use.
D. Bed linens are typically placed in a laundry bag specifically designated for contaminated linens, not in a biohazard bag.
Correct Answer is []
Explanation
- Hypoxia: The client's symptoms of confusion, blue lips (cyanosis), and a low oxygen saturation of 75% on room air indicate severe hypoxia, which requires immediate intervention to restore adequate oxygenation.
- Replace the non-rebreather mask: This action ensures that the client receives the prescribed oxygen therapy at the correct flow rate, which is critical for increasing oxygen levels in the blood.
- Increase the flow of oxygen to 12 L: Adjusting the oxygen flow rate to the prescribed level is necessary to effectively increase the client's oxygen saturation and relieve hypoxia.
- Oxygen saturation: Monitoring oxygen saturation is essential to assess the effectiveness of the oxygen therapy and ensure that the client's oxygen levels are being maintained above 88%, as per the orders.
- Level of consciousness: Monitoring the client’s level of consciousness helps evaluate the impact of hypoxia on the brain and determines whether the interventions are improving the client's neurological status.
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.