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 ["A","B","C","D"]
Explanation
A. Gather an emesis basin, tissues, and a small towel. Nausea and vomiting are common postoperative effects; having supplies ready helps with patient comfort.
B. Lower the bed for easy transfer of the patient. Lowering the bed facilitates a safe and smooth transfer from the stretcher to the bed.
C. Place an IV pole at the head of the bed. The IV should be positioned for easy access and monitoring.
D. Fan fold the sheets on the near side of the bed. Fan folding the sheets makes it easier to transfer the patient into bed without unnecessary movement.
E. Collect extra dressing supplies and place them on the bedside table. Dressing supplies should be kept sterile and only opened when needed to prevent contamination.
Correct Answer is D
Explanation
A. Ask his wife to speak to him to reassure him.
This option is not ideal because the nurse should address the patient's concerns directly. It is important to ensure the patient is making an informed decision and is emotionally supported, but the spouse should not be the first point of contact for reassurance in this case.
B. Assure him that everything will go well.
While it is important to reassure the patient, the nurse should not make promises about the outcome. Assuring the patient everything will go well could lead to unrealistic expectations and may not address the underlying concern.
C. Tear up the surgical consent he signed.
Tearing up the consent is not an appropriate action. The nurse should not act on the patient's uncertainty before consulting the surgeon. The patient has the right to withdraw consent, and this should be addressed properly through communication with the surgeon.
D. Notify the surgeon right away of the situation.
The nurse should immediately notify the surgeon about the patient's change of mind. The surgeon is responsible for providing further clarification and addressing any concerns before proceeding with surgery. The patient must be fully informed and comfortable with their decision.
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