A nurse is caring for a client who has not voided for 8 hours following the removal of an indwelling urinary catheter. Which of the following actions should the nurse take first?

Insert a straight catheter.

Provide assistance to bathroom.

Increase fluids.

Perform a bladder scan.

Answer and Explanation

The Correct Answer is D

A. Inserting a straight catheter may be necessary if the client is unable to void, but it is not the first action. A bladder scan should be performed first to assess for urinary retention or distention before resorting to catheterization.
B. Providing assistance to the bathroom is a reasonable action, but it is more appropriate after performing a bladder scan to assess whether the client is experiencing urinary retention.
C. Increasing fluids might be helpful if the client is dehydrated, but this should not be the first action if there is a concern about urinary retention. A bladder scan should be performed first to assess the situation.
D. Performing a bladder scan is the first action to assess for urinary retention or distention. This non-invasive procedure helps determine if there is a need for catheterization or if other interventions are required.

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Correct Answer is B

Explanation

A. Prolonged immobility does not directly decrease red blood cell (RBC) production. RBC production is primarily regulated by erythropoietin from the kidneys and oxygen demand, which may not be significantly altered by immobility alone.
B. Increased calcium excretion is a well-documented effect of immobility. When a person is immobile, bone resorption increases, leading to the release of calcium into the bloodstream and subsequent excretion through the urine. This can increase the risk of kidney stones and osteoporosis.
C. Immobility typically reduces metabolic demand and insulin sensitivity rather than increasing insulin production. Insulin resistance is more commonly associated with prolonged immobility.
D. Immobility does not directly affect sodium excretion in a way that would cause it to decrease. Sodium balance is primarily regulated by the kidneys and other hormonal mechanisms unrelated to immobility.

A. Exercise regularly to maintain overall health and manage symptoms. B. Engage in activities that increase sleepiness, such as sitting for long periods or being in warm environments, to promote relaxation. C. Avoid taking naps during the day to establish a regular sleep-wake schedule. D. Consume large meals high in carbohydrates to provide energy throughout the day.

Correct Answer is A

Explanation

A. Regular exercise is recommended for individuals with narcolepsy as it helps improve overall health and can reduce symptoms by promoting better sleep at night and increasing daytime alertness.
B. Activities that increase sleepiness, such as prolonged sitting or warm environments, should be avoided as they can exacerbate symptoms of narcolepsy.
C. Short, scheduled naps during the day are actually beneficial for managing narcolepsy symptoms, as they can reduce excessive daytime sleepiness. Avoiding naps entirely can lead to increased fatigue.
D. Large, carbohydrate-heavy meals can increase drowsiness, making them counterproductive for individuals with narcolepsy. Smaller, balanced meals are more appropriate.

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A nurse is caring for a client who has not voided for 8 hours following the removal of an indwelling urinary catheter. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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