The nurse notes that the client's indwelling urinary catheter bag has had no urine output since being emptied 1 hour ago. What should the nurse's first action be?

Ask the client to bear down as if urinating

Check for kinks in the tubing

Increase fluid intake

Insert a new indwelling urinary catheter

Answer and Explanation

The Correct Answer is B

A. Asking the client to bear down as if urinating: This action is not appropriate in this situation because the lack of urine output may not necessarily be due to the client's inability to void. Checking for other potential issues, such as kinks in the tubing, is more appropriate as a first step.

B. Check for kinks in the tubing: This is the most appropriate first action. Kinks in the tubing can obstruct urine flow from the bladder to the drainage bag, leading to decreased or no urine output. By checking for kinks, the nurse can quickly identify and correct any obstructions, potentially resolving the issue without further intervention.

C. Increasing fluid intake: While maintaining adequate hydration is important for overall urinary function, it is not the most immediate action needed when there is no urine output in the catheter bag. Addressing potential mechanical issues, such as kinks in the tubing, takes precedence.

D. Inserting a new indwelling urinary catheter: Inserting a new catheter should not be the first action taken without investigating other potential causes for the lack of urine output. It is important to troubleshoot and address possible issues with the current catheter and drainage system before considering catheter replacement.

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Correct Answer is B

Explanation

A. 17-year-old who has just had an ankle cast applied: While constipation may occur due to reduced mobility after having an ankle cast applied, teaching about the hazards of straining during bowel movements is not the priority for this client. The immediate concern may be related to cast care and mobility.

B. 60-year-old recovering from a heart attack: This client is recovering from a heart attack, and straining during bowel movements can increase intra-abdominal pressure and potentially lead to complications such as vagal stimulation, which may trigger arrhythmias or further stress the heart. Therefore, teaching about the hazards of straining during bowel movements is essential for this client to prevent complications and promote cardiac safety.

C. 80-year-old admitted for an infected tooth: While constipation may occur as a side effect of certain medications or due to decreased oral intake, teaching about straining during bowel movements is not the immediate priority for this client, given the primary reason for admission is an infected tooth. However, if constipation becomes a concern during the admission, it can be addressed accordingly.

D. 28-year-old new mother of twins: While postpartum mothers may experience constipation due to various factors such as changes in hormone levels, reduced mobility after delivery, and opioid use for pain management, teaching about the hazards of straining during bowel movements may not be the priority compared to other immediate postpartum care needs, such as breastfeeding support, perineal care, and newborn care.

A. Support both the client and the family B. Inform the family and client of nurse's personal beliefs C. Carry out the hospital's policies D. Refer the issue to the physician since this is not a nurse's responsibility E. Maximize the client's well being

Correct Answer is ["A","C","E"]

Explanation

A. Support both the client and the family: Nurses have an obligation to support both the client and their family when confronted with an ethical dilemma. This support may involve providing information, facilitating communication, and ensuring that the client's and family's concerns are addressed appropriately.

B. Inform the family and client of nurse's personal beliefs: While nurses may have personal beliefs, it is not ethically appropriate to impose these beliefs on clients or their families. Nurses should maintain professional boundaries and provide care that respects the client's autonomy and values without imposing their own beliefs.

C. Carry out the hospital's policies: Nurses are expected to adhere to the policies and procedures of the healthcare facility where they work. However, if a policy conflicts with ethical principles or legal obligations, nurses should advocate for changes to the policy or escalate the issue through appropriate channels.

D. Refer the issue to the physician since this is not a nurse's responsibility: Nurses have a professional responsibility to address ethical issues within their scope of practice. While collaboration with other healthcare team members, including physicians, is important, nurses should not automatically defer ethical issues to physicians without attempting to address them within their own capacity.

E. Maximize the client's well-being: One of the primary obligations of nurses in ethical dilemmas is to maximize the client's well-being. This includes advocating for the client's rights, providing compassionate care, and promoting the client's best interests while respecting their autonomy and preferences.

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The nurse notes that the client's indwelling urinary catheter bag has had no urine output since being emptied 1 hour ago. What should the nurse's first action be?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is prioritizing the day's interventions. Which client should be the first to be taught about the hazards of straining when having a bowel movement? The:

Correct Answer is B

Explanation

Which of the following is/are nurses' obligation(s) when confronted with an ethical dilemma? (SELECT ALL THAT APPLY)

Correct Answer is ["A","C","E"]

Explanation

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