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 A

Explanation

A. Serum creatinine is a specific marker of renal function and provides an accurate assessment of kidney function, making it the best indicator for evaluating renal health in clients with SLE.
B. Urine-specific gravity indicates the concentration of urine but does not directly assess renal function.
C. Blood urea nitrogen (BUN) can indicate renal function but is less specific than serum creatinine and can be influenced by other factors like hydration status.
D. Serum sodium levels are not a direct indicator of renal function; they are more related to fluid balance and electrolyte status.

A. Limit the number of health care workers entering the room. B. Take the client's temperature once per shift. C. Provide the client with fresh fruit to avoid constipation. D. Insert an indwelling catheter to monitor sediment in the urine.

Correct Answer is A

Explanation

A. Limiting the number of health care workers entering the room helps reduce the risk of infection for immunosuppressed clients, who have weakened immune systems and are more susceptible to infections.
B. For clients with immunosuppression, monitoring the temperature more frequently (e.g., every 4 hours) is important to promptly identify signs of infection.
C. Providing fresh fruit might introduce potential sources of infection; it is safer to provide well-cooked or processed fruits.
D. Inserting an indwelling catheter may increase the risk of infection, and it is generally better to use less invasive methods unless absolutely necessary.

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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?

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