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 A

Explanation

Choice A reason: If the oxygen saturation remains stable during the procedure, it indicates that the suctioning is not adversely affecting the client's oxygenation, and the nurse can safely continue.

Choice B reason: Applying an oxygen mask is not necessary if the oxygen saturation is stable and within a safe range.

Choice C reason: Repositioning the pulse oximeter clip is only necessary if there is a concern about the accuracy of the reading, not when the reading is stable.

Choice D reason: There is no need to stop suctioning if the oxygen saturation is stable at 94%, as this is within the acceptable range for most clients.

A. Unpleasant odor of the breath B. White patches on the mucosa. C. Gumline that has visibly receded. D. Discoloration of several teeth.

Correct Answer is B

Explanation

Choice A reason: While unpleasant odor can indicate poor oral hygiene or other health issues, it is not as urgent as some other findings.

Choice B reason: White patches on the mucosa can indicate an infection such as oral thrush, which requires medical treatment, making it the most important finding to act upon.

Choice C reason: A receding gumline is a concern for dental health but does not typically require immediate action.

Choice D reason: Discoloration of teeth can indicate various issues, including dietary habits or decay, but is not as immediately concerning as white patches on the mucosa. Bolded text indicates the correct answers and important information.

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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?

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Naxlex Comprehensive Predictor Exams

While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?

Correct Answer is A

Explanation

While assisting a client with oral care, the nurse assesses the client's mouth. It is most important for the nurse to take action in response to which finding?

Correct Answer is B

Explanation

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