The patient reports feeling an urge to urinate even though an indwelling urinary catheter is in place. Which is the priority action of the nurse?
Measure the patient's urinary output.
Ensure that the catheter tubing is not kinked.
Provide perineal care to the patient for comfort.
Reassure the patient that the sensation is to be expected.
The Correct Answer is B
A. Measure the patient's urinary output:
Measuring output is important but not the priority. First, the nurse must ensure that urine can drain freely.
B. Ensure that the catheter tubing is not kinked:
This is the priority. A kinked catheter can cause bladder distention and discomfort, leading to a sensation of urgency despite the catheter being in place.
C. Provide perineal care to the patient for comfort:
Comfort is important, but it does not address the potential cause of the urinary sensation.
D. Reassure the patient that the sensation is to be expected:
Sensation may be expected in some patients, but it’s essential to rule out mechanical obstruction first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Return to the room to check and assess the patient:
Patient safety is always the first priority. The nurse must immediately assess the patient for adverse effects or reactions.
B. Administer the antidote to the patient immediately:
This is premature. An antidote is only given if a specific medication and reaction are identified.
C. Alert the charge nurse that a medication error has occurred:
This is necessary after assessing the patient. Reporting comes after immediate safety checks.
D. Complete proper documentation of the medication error in the patient's chart:
Documentation is important but should be done after the patient is assessed and stabilized.
Correct Answer is A
Explanation
A. Do not give the medication:
Nurses should never administer medications prepared by someone else, as this violates the “right medication” and “right patient” principles.
B. Administer the medication just this once:
Even a one-time exception is unacceptable and compromises patient safety and nurse accountability.
C. Give the medication for any pain score greater than 8:
This does not address the issue of medication verification and safety.
D. Avoid the issue and pretend to not hear the request:
This is unprofessional. The nurse should actively refuse and explain the rationale.
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