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 A
Explanation
This is because diarrhea can cause a loss of potassium along with water and other electrolytes. Potassium is an important mineral that helps regulate the heartbeat, nerve impulses and muscle contractions. Low levels of potassium can cause symptoms such as weakness, fatigue, muscle cramps, irregular heartbeat and constipation.
Choice B. Hypocalcemia is wrong because diarrhea does not usually cause a loss of
calcium. Calcium is another mineral that helps with muscle and nerve function, blood clotting and bone health. Low levels of calcium can cause symptoms such as numbness, tingling, muscle spasms, seizures and confusion.
Choice C. Hyponatremia is wrong because diarrhea can cause a loss of sodium, but not to the extent that it causes hyponatremia. Sodium is the most abundant electrolyte in the body and it helps regulate fluid balance, blood pressure and nerve and muscle function. Low levels of sodium can cause symptoms such as headache, confusion, nausea, vomiting, seizures and coma.
Choice D. Hypochloremia is wrong because diarrhea can cause a loss of chloride, but not to the extent that it causes hypochloremia. Chloride is another electrolyte that helps maintain fluid balance, blood pressure and acid-base balance. Low levels of chloride can cause symptoms such as weakness, dehydration, alkalosis (high blood pH) and muscle twitching.
The normal ranges for electrolytes in the blood are:
- Potassium: 3.5 to 5 mEq/L
- Calcium: 8.5 to 10.2 mg/dL
- Sodium: 135 to 145 mEq/L
- Chloride: 96 to 106
Correct Answer is B
Explanation
This meal selection best demonstrates a client with osteoporosis understands dietary recommendations because it provides adequate amounts of calcium, vitamin D, and protein, which are essential nutrients for bone health.
Choice A is wrong because chicken, carrots, and fresh grapefruit salad do not provide enough calcium or vitamin D for a person with osteoporosis.
Calcium is mainly found in dairy products, leafy green vegetables, and fish with bones. Vitamin D is mainly found in fatty fish, egg yolks, and fortified foods.
Choice C is wrong because green salad, ground beef patty, corn, and applesauce do not provide enough calcium or vitamin D for a person with osteoporosis.
Green salad may contain some calcium depending on the type of greens, but it is not a rich source.
Ground beef patty and corn are low in calcium and vitamin
D. Applesauce does not contain any calcium or vitamin
D. Choice D is wrong because plain omelet, bacon, toast with butter, and strawberries do not provide enough calcium or vitamin D for a person with osteoporosis.
Plain omelet and bacon are high in protein but low in calcium and vitamin
Toast with butter may contain some vitamin D if the bread or butter are fortified, but it is not a rich source.
Strawberries do not contain any calcium or vitamin
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