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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Discard the client's last void of the collection time period: The last void must be saved, as it is part of the 24-hr collection.
B. Include toilet paper with the collected urine: Toilet paper must not be included; it contaminates the specimen.
C. Save the first void at the start of the collection time period: The first void is discarded to start the timing and ensure that only the urine produced during the 24 hours is collected.
D. The nurse should discard the first void to obtain an accurate specimen: This is the correct protocol for accurate timing and collection.
Correct Answer is C
Explanation
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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