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

Give the patient 8 ounces (240 mL) of water to drink.

Notify the healthcare provider.

Check the drainage tubing for a kink.

Review the intake and output record.

Answer and Explanation

The Correct Answer is C

Choice A reason: Giving water may be necessary, but it is not the first intervention if there is a concern about urinary output.

Choice B reason: Notifying the healthcare provider is important but should occur after initial assessments and interventions.

Choice C reason: Checking for a kink in the drainage tubing is a quick and simple intervention that may resolve the issue of low output.

Choice D reason: Reviewing the intake and output record is important for understanding the patient's fluid status but is not the first action to take in this situation.

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Correct Answer is ["D","E"]

Explanation

Choice A reason: Oatmeal, cream of wheat, and pureed liquids are not clear liquids and are not appropriate for a clear liquid diet.
Choice B reason: Pureed beans, liquid protein supplements, and milkshakes are not considered clear liquids and should not be included in a clear liquid diet.
Choice C reason: Pureed carrots, creamed soup, and ice cream are not clear liquids because they are not transparent and cannot be consumed on a clear liquid diet.
Choice D reason: Carbonated drinks, gelatin, and broth are considered clear liquids because they are transparent and can be consumed on a clear liquid diet.
Choice E reason: Water, tea without milk or cream, and ice chips are clear liquids and are appropriate for a clear liquid diet.

A. Confirm that bowel sounds are present. B. Measure the client's total body weight. C. Evaluate the client's ability to swallow. D. Observe for signs of fluid volume deficit.

Correct Answer is A

Explanation

Choice A reason: Before initiating tube feeding, it is crucial to ensure that the gastrointestinal system is functioning. The presence of bowel sounds indicates peristalsis, which is necessary for the digestion and absorption of the feeding.

Choice B reason: While measuring the client's total body weight is important for overall assessment and monitoring of nutritional status, it is not the most critical assessment before starting tube feeding.

Choice C reason: Evaluating the client's ability to swallow is not relevant in this scenario since the client will be receiving nutrition through a feeding tube due to malnutrition and dehydration.

Choice D reason: Observing for signs of fluid volume deficit is important, but the immediate concern before starting tube feeding is to confirm gastrointestinal activity through the presence of bowel sounds.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When conducting diet teaching for a client who is on a postoperative clear liquid diet, which foods should the nurse encourage the client to consume? Select all that apply.

Correct Answer is ["D","E"]

Explanation

A client who is admitted for malnutrition and severe dehydration receives a prescription for liquid feedings through a feeding tube. After the feeding tube is inserted and placement confirmed, which assessment is most important for the nurse to complete before starting the feeding?

Correct Answer is A

Explanation

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