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. The right lower quadrant is an anatomical location in the abdomen and is not associated with gas exchange.
B. Gas exchange occurs in the alveoli of the lungs, where oxygen is taken in, and carbon dioxide is expelled.
C. The left ventricle is part of the heart and is involved in pumping oxygenated blood to the body; it is not the site of gas exchange.
D. The trachea is the windpipe that carries air to and from the lungs but is not the specific site of gas exchange.
Correct Answer is D
Explanation
A. Laxative usage is more likely to cause diarrhea or loose stools rather than rectal pain from distended veins.
B. Paralytic ileus is characterized by a lack of bowel motility and is not associated with distention of veins in the rectum.
C. Diarrhea is unlikely to cause pain related to distention of rectal veins.
D. Hemorrhoids are swollen veins in the rectum and anus, causing pain and discomfort, especially during bowel movements.
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