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 C

Explanation

A. While consulting the palliative care team is appropriate for end-of-life care, it is essential first to clarify the client's understanding and wishes regarding "heroic measures" to ensure her preferences are fully understood and respected.
B. Setting up a family conference is important for discussing the client’s wishes with her loved ones, but this should occur after the nurse understands the client's specific desires.
C. The nurse should first discuss with the client what she means by "heroic measures" to ensure that her wishes are clearly understood. This conversation is essential to ensure that any subsequent actions, such as obtaining a DNR order, align with the client’s specific wishes.
D. A DNR prescription is an important step in respecting the client's wishes, but it should only be obtained after confirming exactly what the client means by "heroic measures" and ensuring that she fully understands the implications of a DNR order.

A. Avoids adjusting the height of the hand grips. B. Holds the crutch 6 inches (15 cm) to the side. C. Fits the crutch 2 finger widths from axilla. D. Walks with the arms fully extended.

Correct Answer is C

Explanation

A. Adjusting the hand grips is necessary to ensure that the client can bear weight comfortably through the arms without placing stress on the wrists or shoulders, so avoiding this adjustment is incorrect.
B. Holding the crutch 6 inches to the side is a common guideline, but it is not as crucial as ensuring the correct fit of the crutches to avoid axillary nerve damage and ensure proper posture.
C. The crutch should fit 2 finger widths below the axilla to prevent pressure on the brachial plexus nerves, which can lead to nerve damage. This demonstrates an understanding of proper crutch fit and use.
D. Walking with the arms fully extended is incorrect; the arms should be slightly bent at the elbows to allow for proper weight distribution and movement.

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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

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