A nurse is monitoring the urinary drainage from a patient who returned to the unit a few hours ago from the post anesthesia care unit (PACU) following a surgical procedure. The urine total is 54 mL for the last 2 hours. The most appropriate nursing action is to:
irrigate the indwelling urinary catheter.
notify the surgeon of the findings.
increase the flow rate of the IV for 10 to 15 minutes.
apply manual pressure to the patient's bladder.
The Correct Answer is B
A. Irrigate the indwelling urinary catheter. There is no indication that the catheter is obstructed. Catheter irrigation should only be performed if there is a suspected blockage (e.g., absent urine output, blood clots).
B. Notify the surgeon of the findings. Urine output of less than 30 mL per hour is concerning for decreased renal perfusion, possibly due to hypovolemia or other postoperative complications. The provider should be notified for further evaluation and intervention.
C. Increase the flow rate of the IV for 10 to 15 minutes. Increasing IV fluids may help improve urine output, but it should only be done based on a provider’s order and after assessing the patient’s volume status.
D. Apply manual pressure to the patient's bladder. This action is inappropriate unless the patient has urinary retention, which should be confirmed through assessment before attempting bladder compression
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. To achieve fast-acting pain relief, administer analgesics PO. Oral (PO) medications may not provide rapid pain relief, particularly postoperatively. IV or other forms of analgesia are preferred for fast-acting relief.
B. Consider the client's individual expression of pain. Pain is subjective, and the nurse should consider each patient’s unique expression of pain to provide appropriate pain management.
C. Expect the client to express his pain both verbally and nonverbally. Patients may express pain verbally or nonverbally, such as through facial expressions or body movements. The nurse must be attentive to both forms of expression.
D. Use a scale from 0 to 10 to monitor the severity of the client's pain. The 0 to 10 pain scale is a common and effective tool for assessing the severity of a patient's pain, allowing for appropriate intervention.
E. Administer opioids with caution because they will eventually lead to addiction. While opioids should be used cautiously, the focus should be on appropriate and safe pain management. Addiction is not an immediate concern for postoperative patients who require short-term use.
Correct Answer is D
Explanation
A. Artificial body part. This describes a prosthesis, not an elective procedure.
B. Own, originating within an individual. This describes something intrinsic, such as idiopathic conditions, not elective surgery.
C. To relieve pain or complication without curing. This describes palliative care, not an elective procedure.
D. Voluntary. Elective procedures are planned in advance and performed at the patient’s choice rather than as an emergency (e.g., cosmetic surgery, knee replacement).
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