A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?

Notify the provider.

Adjust the rate of the bladder irrigant.

Irrigate the catheter.

Check the tubing for kinks.

Answer and Explanation

The Correct Answer is D

A. Notifying the provider is important if initial interventions do not resolve the issue, but it is not the first action to take.
B. Adjusting the rate of the bladder irrigant may help, but first, it is essential to ensure that there is no mechanical obstruction in the tubing.
C. Irrigating the catheter can help clear any blockages, but the first step is to check for any kinks or obvious obstructions in the tubing.
D. Checking the tubing for kinks is the first action as it is a common and easily rectifiable cause of urinary catheter drainage issues. This should be done before other interventions.

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Correct Answer is C

Explanation

A. Fresh fruits and vegetables can be contaminated with bacteria and should be avoided or thoroughly washed to prevent infections in clients with neutropenia.
B. The client should monitor their temperature daily, not just weekly, as an elevated temperature can indicate an infection.
C. Avoiding crowds is important for clients with neutropenia to reduce the risk of exposure to infectious agents.
D. While mild exercise can be beneficial, the priority for clients with neutropenia is to avoid potential sources of infection, which includes avoiding public places where infections might be more prevalent.

A. Eyelets are not visible B. Crepitus in the area above and surrounding the insertion site C. Bubbling of the water in the water seal chamber with exhalation D. Movement of the trachea toward the unaffected side

Correct Answer is D

Explanation

A. Eyelets not being visible may be a normal finding, as they can be covered by the dressing. This is not necessarily indicative of a problem with the chest tube.

B. Crepitus, or subcutaneous emphysema, is concerning and should be monitored but is not immediately life-threatening compared to other signs of complications.

C. Bubbling in the water seal chamber with exhalation is expected and indicates that the chest tube is functioning correctly. Continuous bubbling, however, may suggest an air leak.

D. Movement of the trachea toward the unaffected side is indicative of a mediastinal shift, which can occur due to tension pneumothorax or other significant complications. This is an urgent condition that requires immediate provider notification and intervention.

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A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

Correct Answer is D

Explanation

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