A nurse is caring for a client who has a 3-way urinary catheter with continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first?

Notify the provider.

Administer a prescribed analgesic

Determine if there is a link in the tubing

Offer oral fluids.

Answer and Explanation

The Correct Answer is C

A. Notify the provider: While important, this is not the first step. The nurse should assess the equipment before escalation.

B. Administer a prescribed analgesic: There's no indication of pain or need for analgesia at this point. It doesn’t address the lack of output.

C. Determine if there is a kink in the tubing: This is a priority action using the nursing process (Assess first). A kink or blockage is a common and correctable cause of no output.

D. Offer oral fluids: Increasing oral intake won’t help if there's an obstruction in the catheter. First assess and resolve the mechanical issue.

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Correct Answer is D

Explanation

A. Underweight: A BMI <18.5 is considered underweight.

B. Healthy weight: A BMI of 18.5–24.9 is considered a healthy or normal weight.

C. Obese: Obesity is defined as a BMI of 30 or higher.

D. Overweight: A BMI of 25 to 29.9 is classified as overweight, so a BMI of 27 fits this category.

A. Promote active range-of-motion activities. B. Add fluid and fiber to the diet. C. Avoid gas-producing foods. D. Request that the provider prescribe a stool softener.

Correct Answer is B

Explanation

A. Promote active range-of-motion activities: Although helpful, active walking or aerobic activity is more effective than ROM exercises for bowel stimulation.

B. Add fluid and fiber to the diet: Adequate hydration and dietary fiber soften stool and promote regular bowel movements.

C. Avoid gas-producing foods: This might reduce discomfort but does not treat constipation directly.

D. Request that the provider prescribe a stool softener: Non-pharmacological interventions (like diet changes) are first-line unless ineffective.

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A nurse is caring for a client who has a 3-way urinary catheter with continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Explanation

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