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 D

Explanation

A. A PCA pump could be considered, but the immediate action should be ensuring the client understands and follows the prescribed pain management regimen.
B. While explaining potential side effects like respiratory depression is important, this action may increase anxiety about pain management rather than address the client's current concern.
C. Teaching the family how to evaluate the effectiveness of analgesics is important but secondary to ensuring the client is consistently receiving pain relief.
D. Providing the client with a schedule of around-the-clock prescribed analgesic use is crucial in managing pain effectively in hospice care. Consistent pain management, rather than waiting for pain to become severe, is a key principle in palliative care to ensure comfort.

Correct Answer is []

Explanation

Acute pain: The client’s symptoms, such as moaning, facial grimacing, and muscle spasms in the right leg, suggest they are experiencing acute pain. This condition is consistent with the sudden onset of pain and physical reactions.
Request prescription for pain medication: This action addresses the client’s immediate pain needs, helping to alleviate discomfort and improve overall well-being.
Request antispasmodic medication: The muscle spasms observed indicate that an antispasmodic may help reduce the muscle tension and associated pain, providing relief from the spasms.
Response to pain medications: Monitoring the client's response to the prescribed pain medication will help determine the effectiveness of the intervention and whether further adjustments are needed.
Severity of muscle spasms: Assessing the severity of muscle spasms will help evaluate the impact of the antispasmodic treatment and provide insight into the client’s progress in managing the pain.

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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

In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative care nurse is arranging for discharge, the client verbalizes concerns about pain. Which action should the nurse implement?

Correct Answer is D

Explanation

Correct Answer is []

Explanation

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