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
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Correct Answer is D
Explanation
A. Emphysema is not associated with bronchodilation; it is characterized by the destruction of alveoli.
B. Emphysema does not directly increase oxygen saturation; it impairs gas exchange.
C. Emphysema does not affect systole; it primarily affects lung function.
D. Emphysema decreases lung tissue elasticity, leading to decreased compliance, making it harder for the lungs to inflate and deflate.
Correct Answer is B
Explanation
A. This definition is more aligned with the concept of disease prevention and management.
B. Health promotion is defined as the process of enabling individuals to increase control over, and improvement in, their health.
C. This definition is more aligned with the concept of risk reduction.
D. This definition is more aligned with the concept of early intervention and prevention of negative health outcomes.
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