A nurse is looking after a patient who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation.
The nurse observes that there has been no urinary output in the last hour. What should the nurse do first?
Administer a prescribed analgesic.
Check the patency of the tubing.
Notify the provider.
Offer oral fluids.
The Correct Answer is B
Choice B rationale:
Checking the patency of the tubing is the first and most crucial step in addressing the lack of urinary output in this patient. Here's a detailed explanation of why this is the priority action:
Addresses the Most Likely Cause: Obstruction of the urinary catheter tubing is the most common and easily reversible cause of sudden cessation of urinary output in a patient with a continuous bladder irrigation system.
Prevents Complications: A blocked catheter can lead to a number of serious complications, including: Bladder distention, which can cause pain, discomfort, and potential bladder damage.
Urinary retention, which can increase the risk of urinary tract infections (UTIs) and kidney damage. Hematuria, or blood in the urine, due to clot formation in the bladder or catheter.
Non-Invasive Intervention: Checking the tubing is a simple, non-invasive procedure that can quickly identify and resolve the issue without requiring further interventions or delays in care.
Prioritizes Patient Safety: It's essential to promptly address any potential urinary obstruction to prevent the aforementioned complications and ensure patient safety.
Rationale for Other Choices:
Choice A: Administering a prescribed analgesic:
While pain management is important, it does not directly address the lack of urinary output. Pain medication would be appropriate if pain were assessed to be the cause of the decreased output, but it's not the first priority in this situation.
Choice C: Notifying the provider:
Although the provider should be informed of the situation, checking the tubing for patency is a necessary first step to gather more information and potentially resolve the issue quickly without requiring further intervention.
Choice D: Offering oral fluids:
Increasing fluid intake might be helpful in some cases of decreased urinary output, but it's not the priority action in a patient with a continuous bladder irrigation system and a potential catheter obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Distended neck veins are not a reliable indicator of dehydration in adults. They can be caused by other factors, such as heart failure or fluid overload.
In cases of dehydration, the veins in the neck may actually be less visible due to decreased blood volume.
It's important to assess for other signs and symptoms of dehydration, such as urine output, skin turgor, and vital signs, to make an accurate diagnosis.
Choice B rationale:
A bounding pulse can be a sign of dehydration, but it can also be caused by other factors, such as anxiety, exercise, or fever. It's important to assess the pulse rate and rhythm in conjunction with other signs and symptoms to determine the cause.
A normal pulse rate is 60-100 beats per minute in adults. A bounding pulse is typically a strong, forceful pulse that can be easily felt.
Choice C rationale:
A blood pressure of 146/94 mm Hg is considered elevated, but it is not necessarily a sign of dehydration. Blood pressure can be elevated due to other factors, such as stress, pain, or underlying medical conditions. It's important to assess blood pressure in conjunction with other signs and symptoms to determine the cause. Choice D rationale:
Urine specific gravity is a measure of the concentration of solutes in the urine. A higher urine specific gravity indicates more concentrated urine, which is a sign of dehydration.
A normal urine specific gravity is 1.005-1.030. A urine specific gravity of 1.034 is considered high and is a strong indicator of dehydration.
Correct Answer is D
Explanation
NPO status (nothing by mouth) is not a relevant intervention in this situation. It would be indicated for a patient with gastrointestinal issues or prior to a procedure, but it does not address the potential consequences of rapid fluid administration.
Restricting oral intake would not reverse or mitigate the effects of fluid overload that may have already occurred.
It's important to prioritize assessment of the patient's respiratory status, as fluid overload can lead to pulmonary edema, a serious complication.
Rationale for Choice B:
Elevating the head of the bed to high Fowler's position can be helpful in easing breathing for patients with respiratory distress, but it's not the most immediate priority in this case.
Assessing the patient's respiratory status directly through respiratory rate and lung sounds will provide more comprehensive information about potential fluid overload and guide further interventions.
Rationale for Choice C:
Measuring the client's temperature is not directly relevant to the concern of rapid fluid administration.
While fever could be a sign of infection, which might warrant fluid administration, it's not the primary concern in this scenario.
The priority is to assess for potential fluid overload, which could manifest as respiratory distress. Rationale for Choice D:
Checking the client's respiratory rate and lung sounds is the most appropriate action for the nurse to take in this situation.
Rapid infusion of 900 mL of fluid within a short period could lead to fluid overload, which can manifest as: Increased respiratory rate
Crackles in the lungs Shortness of breath Hypoxia
Early identification of these signs is crucial for prompt intervention and prevention of serious complications.
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