LPN Basic Nursing Proctored Exam (fundamentals)
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LPN Basic Nursing Proctored Exam (fundamentals)
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Question: 1 of 26Lpn basic nursing proctored exam (fundamentals)
The nurse notes that a client with a Foley catheter has a distended bladder and no urine output for the past 3 hours. What is the first action?
Explanation
Choice A reason: Removing and reinserting the catheter is invasive and should not be the first step unless obstruction or misplacement is confirmed. Premature removal may introduce infection or trauma, and reinsertion without assessing simpler causes violates standard troubleshooting protocols. Choice B reason: Notifying the healthcare provider is appropriate if initial nursing interventions fail or if the patient shows signs of systemic compromise. However, before escalating, nurses are expected to perform basic assessments to rule out reversible causes such as tubing obstruction. Choice C reason: The first action should be to assess the catheter tubing for kinks or obstruction. This is a non-invasive, immediate intervention that can resolve the issue without further procedures. Blockages due to tubing position, clothing pressure, or dependent drainage bag placement are common and easily corrected. This step aligns with best practices for troubleshooting urinary catheter issues. Choice D reason: Increasing oral fluid intake may help with hydration and urine production, but it does not address the mechanical obstruction or retention issue. If the bladder is already distended, adding more fluid without resolving the blockage may worsen the condition.
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