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 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 D
Explanation
A. Asking vague or nonspecific questions can lead to unclear answers, which may hinder the assessment process. Specific and direct questions are more effective.
B. Starting with the most difficult questions may make the client uncomfortable and less willing to share information. It's better to build rapport first.
C. Sharing personal values is not appropriate as it may influence or pressure the client. The focus should be on the client’s values and experiences.
D. Beginning with questions that are less sensitive helps to build rapport and trust with the client, making them more comfortable discussing more sensitive topics later in the conversation.
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.
