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 C

Explanation

A. Distended neck veins: Distended neck veins are typically associated with fluid overload, not dehydration.

B. High blood pressure: Dehydration usually results in low blood pressure or orthostatic hypotension due to decreased circulating volume.

C. Dark concentrated urine: This is a classic sign of dehydration, indicating low fluid intake and increased urine concentration.

D. Moist skin: Dehydration typically causes dry skin and mucous membranes, not moist skin.

A. Replace the external urinary catheter once each day B. Connect the catheter to continuous wall suction C. insert the catheter into the client's urethra D. Apply a barrier cream to the client's perineal skin

Correct Answer is D

Explanation

A. Replace the external urinary catheter once each day: Replacement depends on the manufacturer's instructions and patient need, not a fixed daily schedule.

B. Connect the catheter to continuous wall suction: External urinary catheters are connected to a gravity drainage bag, not suction.

C. Insert the catheter into the client's urethra: This describes an internal (indwelling) catheter, not an external one.

D. Apply a barrier cream to the client's perineal skin: Barrier creams help protect skin from moisture-associated skin damage and should be used with external catheters.

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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

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