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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. The log rolling technique is specifically intended to maintain straight spinal alignment, which is essential for preventing further injury or complications, particularly for patients with spinal injuries or undergoing post-surgical care. Proper spinal alignment is crucial during the turning process.
B. While working together can help decrease the risk of back injury for nurses, the primary purpose of the log rolling technique is to ensure the client’s spinal alignment.
C. Although using multiple people can enhance safety during the turning process, the main goal of the log rolling technique is to maintain spinal alignment rather than just increasing client safety.
D. Turning instead of pulling helps to reduce skin damage, but the primary reason for using the log rolling technique is to keep the spine aligned, not solely to address skin integrity.

A. Remove the coffee from the tray, advising the client that it is not included in the diet. B. Determine which member of the nursing staff brought the cup of coffee to the client. C. Remind the client that no milk or creamer can be added to the coffee. D. Consult with the dietician to learn if the client is allowed to drink coffee.

Correct Answer is C

Explanation

A. Removing the coffee might not be necessary if coffee is allowed on a clear liquid diet. The client may have been provided with the coffee based on dietary guidelines.
B. Determining which staff member brought the coffee does not address the immediate need to ensure dietary guidelines are followed.
C. On a clear liquid diet, coffee is typically allowed as long as it is consumed without milk or cream. Advising the client about this restriction ensures adherence to the diet and proper management of dietary restrictions.
D. Consulting with the dietician is important for confirming dietary guidelines but addressing the immediate situation with the client’s understanding of their diet is a more direct action.

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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?

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Naxlex Comprehensive Predictor Exams

Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?

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Explanation

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