The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 8-hour shift. Which intervention should the nurse implement first?

Review the intake and output record.

Give the client 8 ounces of water to drink.

Notify the healthcare provider.

Check the drainage tubing for a kink.

Answer and Explanation

The Correct Answer is D

A. Reviewing the intake and output record is important for overall assessment but does not address the immediate issue of low urine output.
B. Giving the client water might be appropriate if the low output is related to dehydration, but the first step is to investigate possible mechanical issues with the catheter.
C. Notifying the healthcare provider might be necessary if there is a persistent problem, but it is important first to identify and address any immediate issues with the catheter.
D. Checking the drainage tubing for a kink is the first step to ensure that the catheter is functioning properly. Mechanical obstruction can cause reduced urine output and should be assessed before taking further actions.

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Correct Answer is A

Explanation

A. A family attorney is the most appropriate professional to contact for more information about advance directives. Attorneys are knowledgeable about the legal aspects of advance directives, including living wills and durable power of attorney for healthcare, and can provide guidance on how to properly complete these documents.
B. A nurse manager may provide general information, but an attorney is more suited to address the legal aspects of advance directives.
C. A hospice nurse focuses on end-of-life care but may not have the expertise to provide comprehensive information about the legal requirements for advance directives.
D. A chaplain can offer spiritual support but is not the best resource for legal information regarding advance directives.

A. Elevate the area and apply light pressure over the site. B. Apply a cold pack to the area for twenty minutes. C. Document the site where the medication was given. D. Notify the healthcare provider of the allergic response.

Correct Answer is C

Explanation

A. Elevating the area and applying light pressure is not appropriate for a small raised area from an intradermal injection, which is usually a normal reaction and not an indication for elevation or pressure.
B. Applying a cold pack is unnecessary and may not be appropriate unless there is significant discomfort or an allergic reaction, which is not suggested by the description of a small, raised area.
C. Documenting the site where the medication was given is important for record-keeping and monitoring the reaction to the intradermal test. This helps in assessing normal reactions versus abnormal ones later.
D. Notifying the healthcare provider of an allergic response should be done if the reaction is severe or unexpected, but a small, round raised area is typically a normal response to an intradermal injection.

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The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 8-hour shift. Which intervention should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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