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. Impaired bed mobility is a concern, especially for an immobile client, but addressing fluid volume deficit takes precedence due to its immediate impact on the client's health.
B. Fluid volume deficit is a critical issue, particularly with diarrhea, which can lead to dehydration and electrolyte imbalances. Ensuring adequate fluid intake and managing fluid balance is essential for preventing complications.
C. Bowel incontinence is a significant issue but managing fluid volume deficit is more urgent to prevent potential complications from dehydration.
D. Caregiver role strain is important, but the immediate priority should be addressing the client’s health needs, such as preventing and managing fluid volume deficit, which can impact overall well-being.

A. Incorporate verbal analogies. B. Offer positive reinforcement. C. Provide physical demonstrations. D. Use simulation activities.

Correct Answer is D

Explanation

A. Verbal analogies can be useful in illustrating points, but they may not fully engage participants in hands-on problem-solving.
B. Positive reinforcement encourages participation, but it is not a problem-solving strategy in itself.
C. Physical demonstrations are helpful for teaching techniques but are less effective for fostering problem-solving abilities.
D. Simulation activities provide a dynamic and interactive way for participants to practice problem-solving. They mimic real-life scenarios, allowing individuals to engage in critical thinking and decision-making, which is especially effective for young adults who learn well through active participation.

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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

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Explanation

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Explanation

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