A client had his Foley catheter removed six hours ago and has just voided for the first time. The nurse performs a bladder scan to check for any post-void residual. The results of the post-void residual (PVR) from the bladder scan are 400mL of urine. What should the nurse do next?

Recognize this as a normal PVR and document the amount in the patient's chart.

Recognize this as an abnormal PVR, call the physician, and recommend an external catheter be applied.

Recognize this as an abnormal PVR, call the physician, and obtain an order for an in-and-out catheterization.

Recognize this as an abnormal PVR and try to have the client void again in a few hours.

Answer and Explanation

The Correct Answer is C

A. This option is incorrect because a PVR of 400 mL is significantly higher than normal. Documenting without further intervention could lead to complications if the high residual volume persists.

B. While an external catheter may be beneficial for managing incontinence or monitoring urine output, it does not address the underlying issue of urinary retention. An external catheter would not relieve the retained urine in the bladder.

C. A post-void residual (PVR) of 400 mL is abnormally high, indicating that the bladder is not emptying effectively, which can lead to discomfort, urinary tract infection (UTI), and potential kidney issues if left untreated. An in-and-out catheterization allows for temporary relief by emptying the bladder and can also help prevent bladder distention. Contacting the physician to report the findings and obtain an order is appropriate to manage this condition safely.

D. Encouraging the client to attempt voiding again without intervention may not be effective in reducing the high PVR. This delay could increase the risk of bladder distention and discomfort.

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Correct Answer is A

Explanation

The correct answer is choice A. After inserting the catheter 2-5 cm, the nurse should then inflate the balloon. It is important to confirm urine return before inflating the balloon to ensure that the catheter is in the correct position and has not entered the bladder neck or prostate. Inflating the balloon before confirming urine return can cause trauma and increase the risk of infection. Option B is incorrect because inflating the balloon too early can cause discomfort, trauma and increase the risk of infection. Option C is incorrect because advancing the catheter too far can cause injury to the bladder or ureters. Option D is incorrect because pulling back the catheter after meeting resistance can also cause trauma to the urethra.

Correct Answer is ["725"]

Explanation

IV Fluid Intake:
- From 0700 to 0900: 2 hours × 100 mL/hr = 200 mL
- From 1030 to 1530: 5 hours × 100 mL/hr = 500 mL
- Total IV Fluid Intake: 200 mL + 500 mL = 700 mL
Antibiotic Infusion Intake:
- Antibiotic Solution: 25 mL
Total Intake Calculation:
- IV Fluid Intake: 700 mL
- Antibiotic Infusion: 25 mL
- Total Intake: 700 mL + 25 mL = 725 mL

Answer: The total intake for the patient from 0700 to 1530 is 725 mL.

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A client had his Foley catheter removed six hours ago and has just voided for the first time. The nurse performs a bladder scan to check for any post-void residual. The results of the post-void residual (PVR) from the bladder scan are 400mL of urine. What should the nurse do next?

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Naxlex Comprehensive Predictor Exams

The nurse is inserting an indwelling urinary catheter for a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon?

Correct Answer is A

Explanation

Correct Answer is ["725"]

Explanation

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