Take full exam for free

A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate. A triple lumen catheter for continuous bladder irrigation with normal saline is infusing, and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?

Discontinue infusing solution.

Irrigate the catheter manually.

Monitor catheter drainage.

Decrease the flow rate.

Answer and Explanation

The Correct Answer is B

A. Discontinuing the infusion may lead to increased clotting and potential obstruction of the catheter. Continuous bladder irrigation is essential to keep the bladder clear of clots and debris following surgery.

B. Manually irrigating the catheter can help clear any clots that may be obstructing the catheter, ensuring adequate drainage and preventing complications such as bladder distention or retention. This is the most immediate and appropriate action to take in response to the presence of clots.

C. Monitoring catheter drainage is important; however, it does not address the potential issue of clots obstructing the flow of urine, which is the priority concern in this scenario.

D. Decreasing the flow rate may not be beneficial and could lead to inadequate irrigation of the bladder, which could exacerbate clot formation and urinary retention.

Free Nursing Test Bank

Take full exam free

View Related questions

A. Wear braces on both wrists during the night. B. Notify the healthcare provider as soon as possible. C. Elevate the hands on two pillows at night. D. Apply cold compresses for 30 minutes before bedtime.

Correct Answer is A

Explanation

A. Wearing braces or splints on both wrists at night helps to keep the wrists in a neutral position, preventing flexion that can worsen symptoms of carpal tunnel syndrome, particularly during sleep when the hands are more likely to be positioned in ways that exacerbate compression of the median nerve.

B. While notifying the healthcare provider is important if symptoms are severe, it is not the immediate teaching intervention the nurse should provide for symptom management.

C. Elevating the hands may help with swelling but is not the primary intervention for managing symptoms of carpal tunnel syndrome, especially pain and tingling.

D. Cold compresses may provide temporary relief but do not address the underlying issue of median nerve compression, which is better managed by using wrist braces.

A. Obtain a sample of the drainage to send to the laboratory. B. Auscultate the abdomen for bowel sound activity. C. Prepare the client to return to the operating room. D. Bring additional sterile dressing supplies to the room.

Correct Answer is C

Explanation

A. Obtaining a sample of the drainage is not an immediate priority after evisceration; the patient's safety and stabilization come first.

B. Auscultating the abdomen for bowel sounds is important but secondary to addressing the immediate crisis of evisceration.

C. Preparing the client to return to the operating room is the priority action because evisceration indicates a surgical emergency that requires prompt intervention to repair the abdominal wall and prevent complications.

D. While additional sterile dressing supplies may be needed, addressing the evisceration takes precedence to prevent further injury and manage the patient’s condition.

Free Nursing Test Bank

Correct Answer is A

Explanation

Correct Answer is C

Explanation

Quick Links

Resources

Free Nursing Test Bank

A client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling experienced worsens at night. Which client teaching should the nurse provide?

Correct Answer is A

Explanation

A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next?

Correct Answer is C

Explanation

Which dietary instruction is most important for the nurse to explain to a client who has had gastric bypass surgery?

When a patient states, "My son hasn't been to see me in months," the nurse's best verbal response is:

A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing plan of care?

The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendation should the nurse encourage the client to follow?

An older adult client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan?

A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor?

A client who works as a data entry clerk is concerned as to how a recent diagnosis of Raynaud's syndrome is going to affect the client's job performance. Which instruction should the nurse provide this client?

Quick Links

Resources