A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr.
Which of the following interventions should the nurse anticipate?
Administer a fluid bolus
Initiate continuous bladder irrigation
Obtain a urine specimen for culture and sensitivity
Clamp the catheter tubing for 30 min
The Correct Answer is A
The correct answer is choice A, administer a fluid bolus.
Choice A rationale:
Administering a fluid bolus is appropriate when a client’s urine output is low, which in this case is less than the minimum expected output of 30 mL/hr. The dark yellow color of the urine also suggests dehydration or concentrated urine, which can be addressed with increased fluid intake.
Choice B rationale:
Initiating continuous bladder irrigation is typically done to clear the urinary tract of blood clots or debris following urologic surgery, not for low urine output or dark urine. Therefore, this intervention is not indicated based on the given scenario.
Choice C rationale:
Obtaining a urine specimen for culture and sensitivity is an action taken when there is a suspicion of a urinary tract infection. The scenario does not provide evidence of infection, such as fever or cloudy urine with a strong odor, so this would not be the first intervention to anticipate.
Choice D rationale:
Clamping the catheter tubing is done in preparation for catheter removal or to assess if the client can void without the catheter. It is not an appropriate intervention for low urine output or dark urine and could potentially cause bladder distention or discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Shuffling gait. This is because shuffling gait is a common manifestation of pseudoparkinsonism, which is a condition that mimics the symptoms of Parkinson’s disease due to the use of certain medications that block dopamine receptors, such as haloperidol. Pseudoparkinsonism can cause slowed movements, muscle stiffness, tremor, and postural instability.
Choice A. Nonreactive pupils is wrong because this is not a typical feature of pseudoparkinsonism or Parkinson’s disease.
Nonreactive pupils can be caused by other conditions, such as brain injury, drugs, or eye diseases.
Choice B. Serpentine limb movement is wrong because this is a characteristic of tardive dyskinesia, another drug-induced movement disorder that can result from long-term use of dopamine receptor blocking agents. Tardive dyskinesia causes involuntary movements of the face, tongue, and limbs that are often writhing or twisting.
Choice C. Smacking lips is wrong because this is also a sign of tardive dyskinesia, not pseudoparkinsonism. Smacking lips is one of the orofacial movements that can occur in tardive dyskinesia due to abnormal muscle contractions.
Correct Answer is D
Explanation
Answer:D. Troponin T test
Rationale:
A. Creatine kinase (CK) test: While creatine kinase isoenzymes, including CK-MB, can be elevated following myocardial infarction (MI), they are not specific to cardiac muscle injury. CK is found in various tissues throughout the body, so elevated levels can also indicate damage to skeletal muscle or brain tissue, among other sources.
B. Creatine kinase-myocardial band (CK-MB) test: CK-MB is a cardiac-specific isoform of creatine kinase, and elevated levels can indicate myocardial injury, particularly in the context of an acute MI. However, troponin T is a more sensitive and specific marker for myocardial injury.
C. Brain natriuretic peptide (BNP) test: Brain natriuretic peptide is primarily used in the diagnosis and management of heart failure. While elevated BNP levels can indicate heart muscle strain or stress, they are not specific markers for acute myocardial infarction or early injury to the cardiac muscle.
D. Troponin T test: This is the correct answer. Troponin T is a highly specific marker for cardiac muscle injury. Elevated troponin levels can be detected within hours of myocardial infarction and persist for several days, making it an essential tool in the diagnosis of acute coronary syndromes, including myocardial infarction. Troponin T is considered one of the gold standard biomarkers for detecting early injury to the cardiac muscle.
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