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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
A colostomy is a surgical procedure that creates an opening in the colon (large intestine) to divert stool through the abdomen. While a colostomy can affect bowel function, it does not directly increase the risk of aspiration. This is because the colon is located further down the digestive tract and does not directly involve the airway.
Choice B rationale:
An ileostomy is a surgical procedure that creates an opening in the ileum (small intestine) to divert stool through the abdomen. Similar to a colostomy, an ileostomy does not directly increase the risk of aspiration because the ileum is also located further down the digestive tract and does not involve the airway.
Choice C rationale:
Enteral feedings, also known as tube feedings, involve delivering nutrients directly into the stomach or small intestine through a tube. Patients receiving enteral feedings through a nasogastric (NG) tube are at a significantly higher risk of aspiration for several reasons:
Impaired swallowing mechanisms: Many patients who require enteral feedings have impaired swallowing mechanisms, which can increase the risk of food or liquid entering the airway instead of the esophagus.
Tube placement: The NG tube itself can potentially irritate the esophagus or interfere with the normal closure of the upper esophageal sphincter, which can increase the risk of reflux and aspiration.
Feeding formula: Enteral feeding formulas are often thin and liquid-like, which can make them easier to aspirate than thicker liquids or solid foods.
Positioning: Patients receiving enteral feedings are often in a reclined position, which can make it easier for fluids to travel back up the esophagus and into the airway.
Choice D rationale:
A chest tube is a drainage tube inserted into the chest cavity to remove air or fluid. While a chest tube can affect respiratory function, it does not directly increase the risk of aspiration. This is because the chest tube drains fluid from the pleural space, which surrounds the lungs, and does not directly involve the airway or digestive tract.
Correct Answer is D
Explanation
The correct answer is choiceD.
Choice A rationale:
Assisting the client back into bed is not the initial action.Moving the client without assessing their condition could potentially cause harm.
Choice B rationale:
Notifying the client’s provider is important, but it should be done after assessing the client’s condition to provide accurate information.
Choice C rationale:
Informing the client’s family member is not the immediate priority.The nurse should first ensure the client’s safety and assess their condition.
Choice D rationale:
Obtaining the client’s vital signs is the initial action.This helps assess the client’s current condition and determine if there are any immediate medical needs.
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