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. Although auscultating breath sounds is important, it is not the immediate priority. The client’s symptoms suggest a possible allergic reaction or anaphylaxis.
B. Elevating the head of the bed is important for comfort but is not the first action in the event of a suspected allergic reaction.
C. Stopping the infusion is the first critical step to prevent further exposure to the allergen and reduce the risk of severe reactions.
D. Calling the provider is important but should occur after ensuring the immediate safety of the client by stopping the infusion.

A. Arteriovenous fistula B. Implanted infusion port C. Short peripheral catheter D. Peripherally inserted central catheter

Correct Answer is D

Explanation

A. An arteriovenous fistula is used for dialysis, not for long-term antibiotic therapy.
B. An implanted infusion port is suitable for long-term therapy but is typically used for medications that require infusions over weeks or months rather than prolonged IV therapy.
C. A short peripheral catheter is not appropriate for extended therapy due to the risk of thrombophlebitis and infiltration.
D. A peripherally inserted central catheter (PICC) is appropriate for long-term intravenous antibiotic therapy as it provides reliable access and reduces the risk of complications associated with extended peripheral catheter use.

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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

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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