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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. One cup of brown rice contains some protein, but it is not a complete protein and provides significantly less protein than lentils. While it can be part of a balanced vegan diet, it is not the best choice for wound healing.
B. Orange juice is rich in vitamin C, which supports collagen formation and wound healing, but it contains negligible protein. It is not a significant source of the macronutrients needed for tissue repair.
C. Lentils are an excellent source of plant-based protein, containing approximately 18 grams of protein per cup. They also provide essential amino acids and nutrients like iron and zinc, which are crucial for wound healing.
D. Avocado is a good source of healthy fats and provides some vitamins, but it is low in protein. While beneficial for overall health, it is not ideal for promoting wound healing due to its low protein content.
Correct Answer is A
Explanation
A. Sunflower margarine fortified with Vitamin B12 is a reliable source for vegans. Vitamin B12 is naturally found in animal products, so fortified foods are often necessary for vegans to meet their nutritional needs. Many plant-based margarines are fortified to provide essential vitamins, including B12.
B. Algae, such as spirulina, contains compounds similar to Vitamin B12, but these are inactive analogs that are not effective for human absorption or use.
C. Sea vegetables, like nori and wakame, may contain trace amounts of Vitamin B12, but the levels are inconsistent and not reliable for meeting daily nutritional requirements.
D. Tempeh, a fermented soy product, does not naturally contain significant amounts of Vitamin B12 unless it has been fortified.
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