A client's bladder is found to be distended. At which location would the nurse begin palpating?

At the symphysis pubis.

In the left lower quadrant.

At the umbilicus.

In the right lower quadrant.

Answer and Explanation

The Correct Answer is A

A. At the symphysis pubis: When the bladder is distended, it typically extends upward from the symphysis pubis. Therefore, the nurse should start palpation here to assess for bladder distention.

B. In the left lower quadrant: This location would be used to assess for structures like the descending colon or potential masses, not the bladder.

C. At the umbilicus: The bladder does not typically reach the umbilical region unless it is severely distended, making this less effective as a starting point.

D. In the right lower quadrant: This area is primarily used to assess structures such as the appendix or ascending colon, not the bladder.

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Correct Answer is C

Explanation

A. The client is terminally ill: DPOA is not automatically activated by terminal illness but by the client’s inability to communicate.

B. The client is incapable of providing self-care: This alone does not activate the DPOA unless they are also unable to make healthcare decisions.

C. The client is unable to express their wishes: Durable power of attorney for healthcare decisions is activated when the client becomes unable to make or communicate their healthcare choices.

D. The client has refused treatment: Refusal of treatment is a decision that an alert and capable client can make independently.

A. Prepare an incident report for risk management. B. Inform the provider of the delay in obtaining the type and cross-match. C. Obtain the client's type and cross-match. D. Document the incident in the client's medical record.

Correct Answer is B

Explanation

A. Prepare an incident report for risk management: While this is necessary, it’s not the priority action as it doesn’t directly address the immediate need for type and cross-matching.

B. Inform the provider of the delay in obtaining the type and cross-match: The nurse should inform the provider first to allow for any changes to the client's preoperative plan. Immediate notification is essential for any follow-up actions, as blood products might be required, or surgery could be rescheduled if the match is not completed.

C. Obtain the client's type and cross-match: This action would be appropriate if it had not already been ordered. Since the order exists, the provider should be informed of the delay first to guide further steps.

D. Document the incident in the client's medical record: Documentation is important but should occur after informing the provider and obtaining the blood work, as it does not directly address the current client care needs.

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A client's bladder is found to be distended. At which location would the nurse begin palpating?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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