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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Correct Answer is B

Explanation

A. White blood cell count is related to immune function and is not directly affected by water intoxication.
B. Serum sodium levels are the primary concern in cases of water intoxication. Excessive water intake can dilute the sodium in the blood, leading to hyponatremia, which can cause confusion, seizures, and other serious complications.
C. While serum potassium levels are important for overall electrolyte balance, they are not as immediately affected by water intoxication as sodium levels are.
D. Creatinine clearance is a measure of kidney function and does not directly relate to the immediate risks associated with water intoxication.

Correct Answer is []

Explanation

Overflow urinary incontinence: The client's condition, which includes wet clothes and sheets with a small volume of urine voided, suggests overflow urinary incontinence, where the bladder is not completely emptied and leaks small amounts of urine.
Place an incontinence containment product under the client: This action helps manage urinary incontinence by absorbing leaked urine and keeping the client dry, thereby preventing skin breakdown and discomfort.
Provide skin care: Regular skin care is essential to prevent skin irritation, breakdown, and potential infections, especially when the client is incontinent.
Intake and output: Monitoring intake and output is crucial in assessing the client's fluid balance and urinary function, ensuring that the incontinence is managed effectively.
Skin integrity: Monitoring skin integrity is necessary to identify any signs of pressure ulcers or skin breakdown, which can result from prolonged exposure to moisture due to incontinence.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses that a client who is disoriented drank eight glasses of water in two hours and is continuing to drink excessive amounts of water. Because the nurse is concerned about water intoxication, which laboratory value should the nurse monitor?

Correct Answer is B

Explanation

Correct Answer is []

Explanation

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