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 B

Explanation

A. Including the caregiver in discussions about pain relief strategies is important, but addressing the client’s immediate concerns and fears should come first.
B. Encouraging the client to talk about her fear related to pain allows the nurse to understand her specific concerns and provide personalized reassurance and support. Addressing the client’s emotional needs is crucial in hospice care.
C. Explaining that analgesics will be given as needed is important for reassurance but may not fully address the client’s fear or allow for an open discussion about her concerns.
D. Providing therapeutic touch and comfort is supportive but does not directly address the client’s fear. Engaging in a conversation about her specific fears allows for more targeted and effective reassurance.

A. Family attorney. B. Nurse manager. C. Hospice nurse. D. Chaplain.

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.

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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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