Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour.
Which of the following actions should the nurse take first?
A. Irrigate the catheter.
Irrigating the catheter may be necessary, but it is not the first action to take.
B. Notify the provider.
Notifying the provider is important, but there are actions the nurse can take first.
C. Check the tubing for kinks.
Checking the tubing for kinks is the first action because it is a simple and non-invasive intervention.
D. Adjust the rate of the bladder irrigant.
Adjusting the rate of the bladder irrigant may be necessary, but it is not the first action to take.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN Custom NURSING 221 Proctored Exam 3. Take the full exam now
Full Explanation
Choice A rationale:
Irrigating the catheter may be necessary, but it is not the first action to take.
Choice B rationale:
Notifying the provider is important, but there are actions the nurse can take first.
Choice C rationale:
Checking the tubing for kinks is the first action because it is a simple and non-invasive intervention.
Choice D rationale:
Adjusting the rate of the bladder irrigant may be necessary, but it is not the first action to take.
Similar Questions
A nurse is caring for a client who has nephrotic syndrome and is receiving high-dose corticosteroid therapy. For which of the following electrolyte imbalances should the nurse monitor?
A. Hypokalemia.
Hypokalemia refers to a lower-than-normal level of potassium in the bloodstream. Normal potassium levels are typically between 3.5 and 5.0 mEq/L. In the context of nephrotic syndrome and high-dose corticosteroid therapy, hypokalemia can occur due to increased urinary potassium losses caused by corticosteroid-induced alterations in kidney function. Corticosteroids can promote the excretion of potassium, leading to a deficiency.
B. Hypomagnesemia.
Hypomagnesemia is a condition where there is a magnesium deficiency in the blood, with normal levels usually ranging between 1.7 and 2.2 mg/dL. While it can occur in nephrotic syndrome due to urinary losses of proteins that bind magnesium, it is not typically associated with corticosteroid therapy. Therefore, it is less likely to be monitored in this specific scenario.
C. Hypermagnesemia.
Hypermagnesemia indicates an abnormally high level of magnesium in the blood. This condition is relatively rare and is not commonly associated with nephrotic syndrome or corticosteroid therapy. It is more often related to renal failure or excessive intake of magnesium-containing medications or supplements.
D. Hyperkalemia.
Hyperkalemia is characterized by an elevated level of potassium in the blood, with normal levels being 3.5 to 5.0 mEq/L. While hyperkalemia can occur in nephrotic syndrome due to the loss of albumin in the urine, which can affect calcium and potassium binding, corticosteroid therapy typically causes a decrease in potassium levels, making hypokalemia a more relevant concern in this context.
Full Explanation
The correct answer is: A
Choice A Reason: Hypokalemia refers to a lower-than-normal level of potassium in the bloodstream. Normal potassium levels are typically between 3.5 and 5.0 mEq/L. In the context of nephrotic syndrome and high-dose corticosteroid therapy, hypokalemia can occur due to increased urinary potassium losses caused by corticosteroid-induced alterations in kidney function. Corticosteroids can promote the excretion of potassium, leading to a deficiency.
Choice B Reason: Hypomagnesemia is a condition where there is a magnesium deficiency in the blood, with normal levels usually ranging between 1.7 and 2.2 mg/dL. While it can occur in nephrotic syndrome due to urinary losses of proteins that bind magnesium, it is not typically associated with corticosteroid therapy. Therefore, it is less likely to be monitored in this specific scenario.
Choice C Reason: Hypermagnesemia indicates an abnormally high level of magnesium in the blood. This condition is relatively rare and is not commonly associated with nephrotic syndrome or corticosteroid therapy. It is more often related to renal failure or excessive intake of magnesium-containing medications or supplements.
Choice D Reason: Hyperkalemia is characterized by an elevated level of potassium in the blood, with normal levels being 3.5 to 5.0 mEq/L. While hyperkalemia can occur in nephrotic syndrome due to the loss of albumin in the urine, which can affect calcium and potassium binding, corticosteroid therapy typically causes a decrease in potassium levels, making hypokalemia a more relevant concern in this context.
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?
A. Restlessness.
Restlessness is a common early sign of increased intracranial pressure (ICP). It can be caused by the brain’s response to the pressure, leading to agitation and restlessness.
B. Tachycardia.
Tachycardia, or a rapid heart rate, is not typically a sign of increased ICP. It can be a response to other factors such as pain, anxiety, or certain medications.
C. Hypotension.
Hypotension, or low blood pressure, is not typically a sign of increased ICP. In fact, hypertension, or high blood pressure, is more commonly associated with increased ICP2.
D. Amnesia.
Amnesia, or memory loss, is not typically a sign of increased ICP. It can be a result of the brain injury itself, but it is not a direct indicator of increased ICP2.
Full Explanation
Choice A rationale:
Restlessness is a common early sign of increased intracranial pressure (ICP). It can be caused by the brain’s response to the pressure, leading to agitation and restlessness.
Choice B rationale:
Tachycardia, or a rapid heart rate, is not typically a sign of increased ICP. It can be a response to other factors such as pain, anxiety, or certain medications.
Choice C rationale:
Hypotension, or low blood pressure, is not typically a sign of increased ICP. In fact, hypertension, or high blood pressure, is more commonly associated with increased ICP2.
Choice D rationale:
Amnesia, or memory loss, is not typically a sign of increased ICP. It can be a result of the brain injury itself, but it is not a direct indicator of increased ICP2.
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?
A. Restlessness.
Restlessness is a common early sign of increased intracranial pressure (ICP). It can be caused by the brain’s response to the pressure, leading to agitation and restlessness.
B. Tachycardia.
Tachycardia, or a rapid heart rate, is not typically a sign of increased ICP. It can be a response to other factors such as pain, anxiety, or certain medications.
C. Hypotension.
Hypotension, or low blood pressure, is not typically a sign of increased ICP. In fact, hypertension, or high blood pressure, is more commonly associated with increased ICP2.
D. Amnesia.
Amnesia, or memory loss, is not typically a sign of increased ICP. It can be a result of the brain injury itself, but it is not a direct indicator of increased ICP2.
Full Explanation
Choice A rationale:
Restlessness is a common early sign of increased intracranial pressure (ICP). It can be caused by the brain’s response to the pressure, leading to agitation and restlessness.
Choice B rationale:
Tachycardia, or a rapid heart rate, is not typically a sign of increased ICP. It can be a response to other factors such as pain, anxiety, or certain medications.
Choice C rationale:
Hypotension, or low blood pressure, is not typically a sign of increased ICP. In fact, hypertension, or high blood pressure, is more commonly associated with increased ICP2.
Choice D rationale:
Amnesia, or memory loss, is not typically a sign of increased ICP. It can be a result of the brain injury itself, but it is not a direct indicator of increased ICP2.