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Ati rn adult med Surg 2023
A nurse in the emergency department is managing the care of a client who has an
electrical shock injury. Which of the following actions should the nurse take first?
A. Change dressings over the entrance and exit wounds. 0%
B. Obtain an ECG. 90% Most selected
C. Administer an opioid pain medication. 3%
D. Titrate IV fluids to maintain urine output at 75 mL/hr. 5%
Answer and Explanation
Choice A:
Changing dressings is important but not the priority over assessing cardiac status in an
electrical shock injury.
Choice B:
Obtaining an ECG is the priority to assess for any cardiac dysrhythmias, which can be
immediate and life-threatening consequences of electrical shock injuries.
Choice C:
Administering pain medication can be done once the client's cardiac status has been
evaluated and stabilized.
Choice D:
While maintaining adequate urine output is important, assessing cardiac status takes
precedence.
,A nurse is assessing a client who is postoperative following a transurethral resection of
the prostate and is receiving continuous bladder irrigation. The client reports bladder
spasms, and the nurse notes a scant amount of fluid in the urinary drainage bag. Which
of the following actions should the nurse take?
A. Apply a cold compress to the suprapubic area. 4%
B. Secure the urinary catheter to the upper left quadrant of the client's abdomen. 4%
C. Use 0.9% sodium chloride to perform an intermittent bladder irrigation. 87%
Most selected
D. Encourage the client to urinate every 2 hr. 3%
Answer and Explanation
Choice A:
This is not a standard intervention for bladder spasms post-TURP.
Choice B:
Securing the urinary catheter to the abdomen does not address the immediate issue of
potential catheter blockage.
Choice C:
Performing an intermittent bladder irrigation using sodium chloride is appropriate in this
case. This is because bladder spasms and a scant amount of fluid in the urinary
drainage bag may indicate a blockage in the catheter. Intermittent bladder irrigation
can help to remove any clots or debris that may be causing the blockage.
Choice D:
Encouraging the client to urinate is not applicable as the client cannot urinate normally
due to the surgery.
, A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV
tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse
should identify that the client is at risk for which of the following conditions?
A. Skin breakdown 2%
B. Infection 88% Most selected
C. Neurogenic bladder 7%
D. Phlebitis 1%
Answer and Explanation
Choice A:
Skin breakdown could occur due to the catheter bag lying in bed, but it is not the primary
risk associated with the observations noted.
Choice B:
A kinked IV tubing can lead to stasis of fluids, which increases the risk of infection.
Additionally, if the urinary catheter bag is not positioned below the level of the bladder,
urine can reflux back into the bladder, which also increases the risk of infection.
Choice C:
Neurogenic bladder is a condition typically associated with nerve damage, not directly
related to the position of the catheter bag or kinked tubing.
Choice D:
Phlebitis is inflammation of a vein, which would not be directly caused by the issues
noted with the urinary catheter.
Ati rn adult med Surg 2023
A nurse in the emergency department is managing the care of a client who has an
electrical shock injury. Which of the following actions should the nurse take first?
A. Change dressings over the entrance and exit wounds. 0%
B. Obtain an ECG. 90% Most selected
C. Administer an opioid pain medication. 3%
D. Titrate IV fluids to maintain urine output at 75 mL/hr. 5%
Answer and Explanation
Choice A:
Changing dressings is important but not the priority over assessing cardiac status in an
electrical shock injury.
Choice B:
Obtaining an ECG is the priority to assess for any cardiac dysrhythmias, which can be
immediate and life-threatening consequences of electrical shock injuries.
Choice C:
Administering pain medication can be done once the client's cardiac status has been
evaluated and stabilized.
Choice D:
While maintaining adequate urine output is important, assessing cardiac status takes
precedence.
,A nurse is assessing a client who is postoperative following a transurethral resection of
the prostate and is receiving continuous bladder irrigation. The client reports bladder
spasms, and the nurse notes a scant amount of fluid in the urinary drainage bag. Which
of the following actions should the nurse take?
A. Apply a cold compress to the suprapubic area. 4%
B. Secure the urinary catheter to the upper left quadrant of the client's abdomen. 4%
C. Use 0.9% sodium chloride to perform an intermittent bladder irrigation. 87%
Most selected
D. Encourage the client to urinate every 2 hr. 3%
Answer and Explanation
Choice A:
This is not a standard intervention for bladder spasms post-TURP.
Choice B:
Securing the urinary catheter to the abdomen does not address the immediate issue of
potential catheter blockage.
Choice C:
Performing an intermittent bladder irrigation using sodium chloride is appropriate in this
case. This is because bladder spasms and a scant amount of fluid in the urinary
drainage bag may indicate a blockage in the catheter. Intermittent bladder irrigation
can help to remove any clots or debris that may be causing the blockage.
Choice D:
Encouraging the client to urinate is not applicable as the client cannot urinate normally
due to the surgery.
, A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV
tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse
should identify that the client is at risk for which of the following conditions?
A. Skin breakdown 2%
B. Infection 88% Most selected
C. Neurogenic bladder 7%
D. Phlebitis 1%
Answer and Explanation
Choice A:
Skin breakdown could occur due to the catheter bag lying in bed, but it is not the primary
risk associated with the observations noted.
Choice B:
A kinked IV tubing can lead to stasis of fluids, which increases the risk of infection.
Additionally, if the urinary catheter bag is not positioned below the level of the bladder,
urine can reflux back into the bladder, which also increases the risk of infection.
Choice C:
Neurogenic bladder is a condition typically associated with nerve damage, not directly
related to the position of the catheter bag or kinked tubing.
Choice D:
Phlebitis is inflammation of a vein, which would not be directly caused by the issues
noted with the urinary catheter.
