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.

Answer and Explanation

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

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Correct Answer is A

Explanation

A. Start with small sips of water at first to see if they are retained. Starting with small sips allows the digestive system to adjust gradually, reducing the risk of nausea, vomiting, or complications from overconsumption after surgery.

B. Wait until his liquid diet tray arrives at mealtime. The patient is eager to try fluids, and waiting for the full meal tray may unnecessarily delay the process of reintroducing fluids.

C. Take in a variety of fluids totaling 3000mls/day. The patient should not be expected to consume a large volume of fluid right away; fluid intake should be gradually increased as tolerated.

D. Go ahead and drink all the water he wants. Allowing the patient to drink freely can overwhelm the digestive system and may cause complications, such as nausea or vomiting.

A. Distract the client by giving him reading material. B. Suggest that he take a walk around the unit. C. Ask him to describe his concerns. D. Refer him to the spiritual care team.

Correct Answer is C

Explanation

A. Distract the client by giving him reading material. Distraction may not address the underlying anxiety and could delay processing the client's concerns about the surgery.

B. Suggest that he take a walk around the unit. While walking can help with anxiety in some patients, it does not directly address the client's expressed concern about the surgery itself.

C. Ask him to describe his concerns. The nurse should acknowledge the patient's feelings by encouraging them to express their concerns. This helps reduce anxiety and provides valuable information for further support.

D. Refer him to the spiritual care team. While spiritual care may be beneficial later, it’s essential to first address the patient’s immediate concerns before referring them to other services.

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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:

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Naxlex Comprehensive Predictor Exams

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Explanation

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