This question tests risk reduction in NG and urinary catheter care. The key risk in this scenario is infection from contamination when the drainage bag touches the floor, potentially introducing bacteria. Hanging the drainage bag on the bed frame below bladder level without allowing it to touch the floor effectively reduces the risk by preventing microbial ascent and promoting gravity drainage. Emptying into the toilet (B) risks splashing; disconnecting (C) opens the system; clamping (D) causes stasis. A key principle of catheter care is keeping the bag off the floor and below the bladder to control infection. Another principle is maintaining a closed system for patency and hygiene. A strategy for monitoring includes checking bag position during transfers and assessing urine clarity to detect early contamination.

This question tests risk reduction in NG and urinary catheter care. The key risk in this scenario is aspiration or respiratory distress from nasogastric tube displacement into the airway, indicated by coughing and changed markings. Stopping the suction, assessing respiratory status, and notifying the registered nurse or provider per policy effectively reduces the risk by preventing further harm and ensuring prompt intervention. Irrigating with air (B) is unsafe without confirmation; offering water (C) risks aspiration; advancing the tube (D) could worsen displacement. A key principle of catheter care is verifying placement before use to maintain safety. Another principle is immediate response to signs of displacement to prevent complications. A strategy for monitoring includes checking tube markings and respiratory status every shift to detect early dislodgement.

This question tests risk reduction in NG and urinary catheter care. The key risk in this scenario is nasogastric tube malfunction causing nausea and potential aspiration from lack of decompression. Assessing the suction equipment and tubing for disconnection or kinks and ensuring prescribed suction is functioning effectively reduces the risk by restoring drainage. Administering antiemetic (B) treats symptom; offering fluids (C) risks aspiration; removing tube (D) is unauthorized. A key principle of catheter care is equipment checks for patency. Another principle is immediate troubleshooting. A strategy for monitoring includes hourly drainage and symptom assessment to detect malfunctions early.

This question tests risk reduction in NG and urinary catheter care. The key risk in this scenario is urinary catheter obstruction leading to decreased output and abdominal pressure postoperatively. Assessing the catheter tubing for kinks or obstruction, ensuring the bag is below the bladder, and notifying the registered nurse effectively reduces the risk by promoting flow and escalating care. Irrigating without prescription (B) is unauthorized; removing (C) is premature; increasing fluids (D) doesn't address patency. A key principle of catheter care is checking for mechanical issues to maintain patency. Another principle is collaboration for interventions outside scope. A strategy for monitoring includes hourly output measurement and abdominal assessment to detect retention early.

A gastric residual volume of 150 mL combined with the subjective report of bloating indicates that the client is not adequately digesting the previous feeding and the stomach has not emptied. Adding a bolus feeding on top of an already distended stomach increases the risk of aspiration, vomiting, and abdominal discomfort. The aspirate should be re-instilled into the tube before clamping: this preserves electrolytes and digestive enzymes that would be lost if discarded. The feeding is then delayed for approximately one hour, after which gastric residual is re-checked. The nurse should notify the PHCP if residuals remain elevated at the next assessment or if the client develops worsening symptoms. Proceeding with the feeding despite a high residual (A or B) risks aspiration. Supine positioning (D) is contraindicated for tube feedings — the head of the bed should be elevated at least 30 to 45 degrees.

Once the non-dominant hand has touched the client to maintain labia exposure during cleansing, that hand is considered contaminated and must remain in position — it cannot touch the sterile field, the catheter, or any sterile equipment. The dominant hand, which has not touched the client and remains sterile, is used to pick up the catheter (already lubricated from the kit preparation step) and insert it into the urethral meatus. For female catheterization, the catheter is advanced 2 to 3 inches (5 to 7.5 cm) or until urine returns. Releasing the labia (B) would close the exposure and risk contaminating the insertion site. Using the non-dominant hand to pick up the catheter (D) is a sterile technique violation because that hand is no longer sterile. Bearing down (C) is not standard technique for catheter insertion — deep breathing and relaxation are encouraged.

When an NG tube connected to suction produces no drainage, the nurse must systematically troubleshoot from the least invasive step first. Checking for kinks, dependent loops of fluid in the tubing, or disconnections in the system takes only seconds, does not require touching the client's tube, and can immediately identify the most common cause of drainage loss. If no mechanical obstruction is found, the nurse can then irrigate with 30 mL of sterile normal saline (C) to check tube patency. Increasing to high continuous suction (A) without first investigating the cause risks mucosal injury if the tube is against the gastric wall. Notifying the provider (B) is appropriate if simpler troubleshooting steps fail, but checking for kinks must come first.

Severe, sharp lower abdominal pain combined with a strong urge to urinate in a client with an indwelling catheter are the primary clinical cues of bladder distension from catheter obstruction. These symptoms occur because the bladder continues to fill with irrigation fluid but cannot drain, creating rapid and painful over-distension. When the nurse subsequently confirms absent drainage and palpable bladder distension (at 1005), the cues align into a clear obstruction presentation. The client's age (A) is a demographic factor that increases surgical risk but does not indicate obstruction. Light pink drainage earlier (C) was an expected and reassuring post-TURP finding — a change from this normal baseline toward absent drainage is the alert. The type of catheter (B) explains the clinical setup but is not a finding indicating obstruction.

In continuous bladder irrigation, if the outflow channel is blocked while the inflow channel continues running, the bladder rapidly over-distends with irrigating fluid. In the post-TURP surgical client, this is most commonly caused by a blood clot obstructing the catheter tip. Uncorrected, the over-distension can cause severe bladder spasm, stretch injury to the bladder wall, and — in its most serious form — bladder rupture. In a client with a raw TURP surgical site, the increased intravesical pressure can also disrupt the surgical bed and precipitate significant hemorrhage. This is a urological emergency requiring immediate nursing intervention. Acute kidney injury (A) is a more distal consequence of prolonged obstruction — the immediate risk is at the bladder level, not the kidneys. Allergic reaction to catheter material (C) is not an acute complication of acute obstruction. Systemic bloodstream infection (B) is a longer-term risk of catheterization, not the immediate complication of acute outflow obstruction.

Post-TURP catheter obstruction is most commonly caused by a blood clot lodging at the catheter tip or within the drainage channel. Manual irrigation with sterile normal saline using a piston syringe is the definitive intervention to mechanically dislodge and flush the clot, restoring outflow. This is an expected and standard nursing skill in post-TURP care. Slowing the CBI rate (B) slightly reduces the rate of fluid accumulation but does not address the existing clot obstruction — the bladder will continue to distend, just more slowly. Increasing oral fluids (C) is completely counterproductive in an obstructed system — adding more fluid when drainage is blocked worsens distension. Prone positioning (D) has no therapeutic effect on catheter obstruction and is inappropriate for a post-operative client with a fresh surgical site.