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 B

Explanation

Choice A reason: Skin turgor is a method to assess hydration status, but it is not the most accurate indicator of fluid balance in a patient with fluid volume overload.

Choice B reason: Monitoring weight is the most accurate method to assess fluid balance. A sudden increase or decrease in weight is indicative of fluid changes.

Choice C reason: Blood pressure can be affected by fluid volume changes, but it does not provide a direct measure of fluid balance.

Choice D reason: Lung sounds can indicate fluid overload in the lungs but do not give a complete picture of overall fluid balance.

A. Assess for sources of pain other than the surgical site. B. Change to a behavioral pain scale. C. Give a dose of 2.5 mg of morphine. D. Refer to social work for drug-seeking behavior. E. Bring an opioid reversal agent to the bedside. F. Lead the client in guided imagery. G. Consult with the surgeon about the pain level. H. Helping the client walk around the room.

Correct Answer is ["A","C","G","H"]

Explanation

Choice A reason:
The increase in heart rate from 78 to 118 beats per minute, along with the increase in pain rating from 3 to 8, suggests that the client may be experiencing pain from a source other than the surgical site. It is important to assess for other potential sources of pain to ensure comprehensive pain management.
Choice B reason:
Changing to a behavioral pain scale is not indicated in this scenario. The numerical pain scale is a standard and effective method for assessing pain levels, and there is no indication that the client has difficulty communicating her pain using this scale.
Choice C reason:
Given that the client's pain rating increased to 8, which is above the threshold of 4 on the pain scale, administering a dose of 2.5 mg of morphine as per the orders is appropriate to manage her pain.
Choice D reason:
Referring to social work for drug-seeking behavior is not supported by the information provided. The client's increased pain rating and heart rate suggest a legitimate need for pain management rather than drug-seeking behavior.
Choice E reason:
Bringing an opioid reversal agent to the bedside is not indicated unless there is a concern for opioid overdose, which is not suggested by the information provided.
Choice F reason:
While guided imagery can be a helpful adjunct for pain management, it is not the primary intervention needed at this time given the client's significant increase in pain and heart rate.
Choice G reason:
Consulting with the surgeon about the client's increased pain level is important to rule out any complications from the surgery and to discuss further pain management strategies.
Choice H reason:
Assisting the client to walk around the room may help in pain management and is part of the postoperative care plan to increase walking distance. However, it should be done cautiously considering the client's current pain level.

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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

A patient with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the patient's fluid balance?

Correct Answer is B

Explanation

Patient Data Exhibits Based on the trending heart rate and pain score, what should the nurse do? Select all that apply.

Correct Answer is ["A","C","G","H"]

Explanation

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