Nokea
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?
- A. Give the patient 8 ounces (240 mL) of water to drink.
- B. Notify the healthcare provider.
- C. Check the drainage tubing for a kink.
- D. Review the intake and output record.
Correct Answer: C
Rationale: Checking tubing addresses potential obstruction.
You may also like to solve these questions
A client with end-stage lung disease is dependent on a mechanical ventilator to sustain life. While the client's spouse is at the bedside, the client pleads in handwritten notes to have the endotracheal tube removed. The spouse tearfully agrees with the request. Which is the priority nursing intervention?
- A. Offer to contact the family's spiritual counselor to meet with the client and spouse.
- B. Discuss comfort measures with the client and family that will be available during withdrawal.
- C. Inform the healthcare provider of the client's desire to have life support withdrawn.
- D. Explain the actions that the healthcare team will follow for the removal of life support.
Correct Answer: C
Rationale: Notifying provider respects client autonomy.
The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during respiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?
- A. Increase the liter flow of oxygen.
- B. Encourage the client to take deep breaths.
- C. Remove the mask to deflate the bag.
- D. Document the assessment data.
Correct Answer: A
Rationale: Increasing flow ensures oxygen delivery.
The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home, and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?
- A. Bowel incontinence.
- B. Impaired bed mobility.
- C. Fluid volume deficit.
- D. Caregiver role strain.
Correct Answer: C
Rationale: Dehydration from diarrhea is life-threatening.
To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes but does not feel a pulsation. Which action should the nurse take next?
- A. Reduce the amount of pressure being applied on the top of the foot.
- B. Document in the nurse's notes that the dorsalis pedis pulse is not palpable.
- C. Obtain a Doppler stethoscope to auscultate the pulse at the same site.
- D. Palpate the site on the inner side of the ankle below the medial malleolus.
Correct Answer: C
Rationale: Doppler detects weak pulses.
The nurse observes an unlicensed assistive personnel (UAP) providing care for two clients using the same gloves. Which action should the nurse take first?
- A. Praise the UAP for using standard precautions.
- B. Instruct the UAP to change gloves immediately.
- C. Request that an in-service program be scheduled on asepsis.
- D. Submit an adverse occurrence report to the unit manager.
Correct Answer: B
Rationale: Changing gloves prevents cross-contamination.