The nurse receives a report that a patient with an indwelling urinary catheter has an output of 150 mL for the previous 8-hour shift. Which intervention should the nurse implement first?

Give the patient 8 ounces (240 mL) of water to drink.

Notify the healthcare provider.

Check the drainage tubing for a kink.

Review the intake and output record.

Answer and Explanation

The Correct Answer is C

Choice A reason: Giving water may be necessary, but it is not the first intervention if there is a concern about urinary output.

Choice B reason: Notifying the healthcare provider is important but should occur after initial assessments and interventions.

Choice C reason: Checking for a kink in the drainage tubing is a quick and simple intervention that may resolve the issue of low output.

Choice D reason: Reviewing the intake and output record is important for understanding the patient's fluid status but is not the first action to take in this situation.

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Correct Answer is C

Explanation

The correct answer is choice c. Place padding around the cannula tubing.

Choice A rationale:

Discontinuing the use of the nasal cannula is not appropriate because the client still needs supplemental oxygen to maintain adequate oxygen saturation levels.

Choice B rationale:

Applying lubricant to the cannula tubing might help reduce friction but does not address the pressure that is causing the red mark.

Choice C rationale:

Placing padding around the cannula tubing helps to alleviate the pressure on the skin, which can prevent further irritation and allow the red mark to heal.

Choice D rationale:

Decreasing the flow rate to 1 L/minute could compromise the client’s oxygenation status, as the current flow rate is necessary to maintain an oxygen saturation level of 94%.

A. Increase the liter flow of oxygen. B. Encourage the client to take deep breaths. C. Remove the mask to deflate the bag. D. Document the assessment data.

Correct Answer is A

Explanation

Choice A reason: If the oxygen reservoir bag of a partial rebreather mask does not deflate completely during inspiration, it may indicate that the flow rate is too low. Increasing the liter flow ensures adequate delivery of oxygen.

Choice B reason: Encouraging the client to take deep breaths is beneficial for overall respiratory function but will not address the issue of the reservoir bag not deflating properly.

Choice C reason: Removing the mask to deflate the bag is not a standard practice and could interrupt the delivery of oxygen to the client.

Choice D reason: Documentation of the assessment data is important, but the nurse must first address the issue with the oxygen delivery system to ensure the client is receiving the proper amount of oxygen.

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The nurse receives a report that a patient 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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