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 A

Explanation

Choice A rationale: Excessive pressure can occlude arterial flow, preventing detection of the dorsalis pedis pulse. Reducing pressure allows blood flow to be felt, improving accuracy of pulse assessment.

Choice B rationale: Documentation without rechecking risks inaccurate reporting. Pulses may be present but obscured by technique, so confirming with proper palpation or alternative methods is necessary before recording findings.

Choice C rationale: Doppler stethoscope is useful but should be considered after correcting palpation technique. Initial step is adjusting pressure, as improper technique commonly explains absent pulse detection.

Choice D rationale: Palpating posterior tibial pulse assesses a different artery. While useful for circulation evaluation, it does not address the immediate issue of dorsalis pedis pulse palpation technique.

A. Obtain the specimen from the client's current bowel movement. B. Contact the healthcare provider before obtaining the specimen. C. Wait to obtain the specimen until observable blood is present. D. Withhold specimen collection until tarry black stool is observed.

Correct Answer is A

Explanation

Choice A reason: The presence of soft, formed, and light brown feces is normal and does not preclude testing for occult blood. The nurse should proceed with obtaining the specimen as ordered.
Choice B reason: There is no need to contact the healthcare provider before obtaining the specimen if the stool appears normal and the test for occult blood has been ordered.
Choice C reason: Waiting for observable blood is not necessary for an occult blood test, which is designed to detect blood that is not visible to the naked eye.
Choice D reason: Withholding specimen collection until tarry black stool is observed is not indicated. Tarry black stool can indicate bleeding in the upper gastrointestinal tract, but the test for occult blood is used to detect blood that may not be visible in the stool. Bolded text indicates the correct answers and important information.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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