The nurse is assessing the urinary output of a patient 4 hours after a caesarean birth. The patient weighs 68 kg and the indwelling catheter bag measures 125 mL of urine. Which action will the nurse include in the plan of care?

Discontinue the indwelling catheter.

Increase intravenous fluid rate.

Check the catheter for patency.

Document the finding.

Answer and Explanation

The Correct Answer is C

Choice A reason: Discontinuing the indwelling catheter is not appropriate without first assessing the cause of the low urine output.

Choice B reason: Increasing the intravenous fluid rate might be considered if the patient is dehydrated, but first, the nurse should ensure that the low urine output is not due to a mechanical issue with the catheter.

Choice C reason: Checking the catheter for patency is the most immediate and appropriate action. There could be a blockage or kink in the catheter, which might explain the low urine output.

Choice D reason: Documenting the finding is important, but it should be done after addressing the immediate concern of low urine output and confirming that the catheter is functioning properly.

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Correct Answer is C

Explanation

Choice A reason: Concerns about physical development, such as not having had a growth spurt yet, are common among adolescents. While this statement indicates some distress, it is generally considered a normal part of adolescent development and may not require immediate intervention.

Choice B reason: Feeling infantilized by parents is also a common issue among teenagers. This can be addressed through communication and support, but it is not typically an urgent matter.

Choice C reason: Statements about social isolation and feeling disliked by peers can be indicative of significant emotional distress or even depression. This statement warrants immediate attention to assess the adolescent's mental health and provide necessary support or intervention.

Choice D reason: Stress related to academic pressures, such as a big project, is common among students. While it is important to address stress management, it does not typically indicate an immediate risk to the student's well-being.

A. Allow medical staff to make the plan of care decisions. B. Assessing the family's home environment. C. Arranging the necessary care equipment and supplies. D. Referring to financial support.

Correct Answer is A

Explanation

Choice A reason: Allowing medical staff to make the plan of care decisions without involving the patient and their family indicates a lack of patient-cantered care, which is a critical component in effective discharge planning. The patient and family members should be actively involved in the decision-making process to ensure that the plan of care aligns with their needs, preferences, and unique circumstances. Education on the importance of collaboration and shared decision-making in care planning is essential.

Choice B reason: Assessing the family's home environment is a necessary step in discharge planning. This intervention ensures that the patient will have a safe and supportive environment to return to, which can significantly impact their recovery and well-being. It includes evaluating factors such as accessibility, availability of caregivers, and any potential hazards that might affect the patient's health.

Choice C reason: Arranging the necessary care equipment and supplies is an important part of discharge planning to ensure that the patient has all the resources needed to continue their care at home. This includes medical equipment, medications, and other supplies that support the patient's health and recovery. Proper planning and arrangement of these resources prevent gaps in care and promote a smooth transition from hospital to home.

Choice D reason: Referring to financial support is a critical intervention, especially for patients with complex medical histories who may face significant healthcare costs. Financial support can help alleviate the burden of medical expenses and ensure that the patient has access to necessary services and treatments. The nursing student needs to understand the importance of connecting patients with financial resources and support programs.

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The nurse is assessing the urinary output of a patient 4 hours after a caesarean birth. The patient weighs 68 kg and the indwelling catheter bag measures 125 mL of urine. Which action will the nurse include in the plan of care?

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