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. Lower the patient back to the side of the bed, pivot her back into the bed, and assess the patient's vital signs. When a patient reports feeling faint while attempting to stand, it is important to take immediate action to prevent a fall and ensure patient safety. Lowering the patient back to the bed will help prevent injury in case of a fall. Then, the nurse should pivot the patient back into the bed slowly and safely. Once the patient is lying down, assess the vital signs, particularly the blood pressure and heart rate, to ensure that the patient is stable. This information can help the nurse determine if the patient is experiencing postural hypotension or other complications from surgery. After assessing the vital signs, the nurse can report the findings to the healthcare provider and implement appropriate interventions to help prevent future episodes of fainting.

A. Act as if you are still taking the radial pulse while assessing respiratory rate so the client does not know you are counting. B. If the respiratory rate is regular, count for 30 seconds and multiply by 2. C. Observe the depth and rhythm of the respirations. D. Count a full respiratory cycle (inhalation and exhalation) E. Count a full respiratory cycle (inhalation and exhalation)

Correct Answer is ["B","C","D"]

Explanation

The correct answer is choices B, C, and D.

When assessing respiratory rate, it is important to count for a full respiratory cycle, which includes both inhalation and exhalation. If the respiratory rate is regular, the nurse can count for 30 seconds and multiply by 2 to obtain the total number of breaths per minute. The nurse should also observe the depth and rhythm of the respirations, noting any abnormalities or changes. It is not recommended to pretend to take the radial pulse while assessing respiratory rate, as this can lead to inaccurate readings and is not a professional approach to care

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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

A nurse is assisting a patient who is 2 days postoperative from an abdominal surgery to sit in a chair. After assisting the patient to the side of the bed and to stand up, the patient tells the nurse she feels faint. What should be the nurse's immediate action to keep the patient safe?

Correct Answer is A

Explanation

A nurse is instructing a group of nursing students in taking vital signs and assessing a client's respiratory status. Which of the following guidelines should the nurse include? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

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