A client has not voided eight hours after surgery and says to the nurse, “I don’t think I can urinate.” What should be the first action for the nurse?
Assess the client’s bladder.
Administer pain medication.
Increase the client’s fluid intake.
Inform the surgeon of the client’s status.
The Correct Answer is A
The nurse should first assess the client’s bladder for distention by palpating the lower abdomen between the symphysis pubis and the umbilicus.
This can indicate urinary retention, which is a common postoperative complication. The nurse should also measure the bladder volume using a bladder scanner if available.
Choice B. Inform the surgeon that the client’s status is wrong because the nurse should first assess the client before notifying the surgeon.
The surgeon may order interventions based on the assessment findings.
Choice C. Increasing the client’s fluid intake is wrong because increasing fluid intake may worsen bladder distention and discomfort.
The nurse should encourage fluid intake only after ensuring adequate urinary output.
Choice D. Administering pain medication is wrong because pain medication may not be indicated for urinary retention.
Pain medication may also cause urinary retention by relaxing the bladder muscles and impairing the micturition reflex.
Normal urine output is about 30 mL per hour or 240 mL in eight hours.
The nurse should monitor the client’s intake and output and report any signs of urinary retention to the surgeon.
Urinary retention can lead to infection, bladder damage, and renal impairment if not treated promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Interview the client privately and ask if anyone is harming her.
This is because the nurse has a duty to assess the client for possible elder abuse and report any suspicions to the appropriate authorities.
The nurse should not assume that the son is the abuser or that the client will disclose the abuse without being asked directly.
The nurse should also respect the client’s autonomy and privacy and not confront the son or provide an elder abuse brochure without the client’s consent.
Choice A is wrong because it may imply that the client is responsible for preventing the abuse or that the nurse has already made a judgment about the situation.
It may also be ineffective if the client is unable or unwilling to read the brochure or seek help. Choice C is wrong because it may delay the assessment and intervention for the client.
It may also be biased and unfair to observe the son without interviewing him or the client first.
Choice D is wrong because it may violate the client’s rights and preferences.
It may also be premature to report the abuse without confirming it with the client or obtaining more evidence.
Correct Answer is C
Explanation
This is because it shows a normal pH, pCO2, HCO3 and pO2, indicating that the treatment has been effective in restoring normal gas exchange and acid- base balance.
Choice A is wrong because it shows a low pH, high pCO2 and high HCO3, indicating a mixed respiratory and metabolic acidosis.
Choice B is wrong because it shows a low pH, high pCO2 and low HCO3, indicating a combined respiratory and metabolic acidosis.
Choice D is wrong because it shows a high pH, low pCO2 and low HCO3, indicating a mixed respiratory and metabolic alkalosis.
The normal ranges for arterial blood gas (ABG) are:
- pH: 7.35 – 7.45
- pO2: 10 – 14 kPa or 75 – 105 mmHg
- pCO2: 4.5 – 6 kPa or 34 – 45 mmHg
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