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 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.

A. True B. False

Correct Answer is D

Explanation

General anesthesia involves the administration of inhaled or intravenous agents that induce unconsciousness, analgesia, and muscle relaxation. Nerve blocks (spinal, caudal, epidural, and peripheral blocks) are forms of regional anesthesia, not general anesthesia.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is scheduled to undergo abdominal surgery and tells the nurse that he is very anxious about the operation. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

General Anesthesia is when a nerve block such as a spinal, caudal, epidural, or peripheral block is administered. (Write True or False)

Correct Answer is D

Explanation

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