A client had his foley catheter removed eight hours ago and is unable to void. The nurse performs a bladder scan to check bladder volume. The bladder scan demonstrates more than 600mL of urine in the bladder. What should the nurse do next?
Palpate the abdomen for a distended bladder.
Document finding as normal volume.
Immediately perform In & Out catheterization per standing order from provider.
Recheck bladder scan in 6 hours.
The Correct Answer is C
A. Palpating the abdomen may provide additional information but is not the next step in this situation.
B. Documenting the finding as normal volume is not appropriate; a bladder volume of more than 600mL is considered significant.
C. Performing In & Out catheterization is the next step to relieve urinary retention.
D. Rechecking the bladder scan in 6 hours is not appropriate when immediate intervention is needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Diarrhea, flatulence, and decreased turgor are not typically associated with hypoxia.
B. Hypoxia manifests with dyspnea (difficulty breathing), tachycardia (increased heart rate), and cyanosis (bluish discoloration of the skin).
C. Hypotension, edema, and erythema are not primary signs of hypoxia.
D. Chest pain, dry skin, and petechiae are not specific to hypoxia.
Correct Answer is ["660"]
Explanation
To calculate the total output for this patient, we need to add up the amount of fluid that he lost through urination and emesis. Urination is the process of expelling urine from the body, and emesis is the medical term for vomiting. The patient urinated 300mL in the morning and 300mL at lunch, so the total amount of urine output is 600mL. The patient also had 60mL of emesis after lunch, so the total amount of emesis output is 60mL. Therefore, the total output for this patient is 600mL + 60mL = 660mL.
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