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 D

Explanation

A. Keeping spare crutch tips handy is a good practice to ensure safety in case the current tips wear out or become damaged.
B. Inspecting crutches daily for signs of wear, such as cracks or loose screws, is essential to prevent accidents and ensure the crutches remain safe to use.
C. Bearing weight on the hands instead of the underarms is correct to avoid nerve damage (e.g., axillary nerve injury) and discomfort.
D. Using someone else's crutches is unsafe because they may not be adjusted to the client’s height and weight, potentially leading to improper use and injury. Each client should use crutches specifically fitted for their needs.

A. Check the residual feeding contents B. Verify tube placement C. Evaluate tolerance of feeding D. Administer the feeding

Correct Answer is B,A,D,C

Explanation

A. Check the residual feeding contents to assess gastric emptying and determine if the client is tolerating previous feedings. High residuals may indicate delayed gastric emptying and require provider notification.

B. Verify tube placement to ensure the NG tube is in the stomach or small intestine and not in the respiratory tract. This can be done by testing the pH of gastric aspirate or confirming placement through other approved methods.

C. Evaluate tolerance of feeding by monitoring for signs of discomfort, nausea, vomiting, or abdominal distension. Document findings and adjust care as needed.

D. Administer the feeding at the prescribed rate and volume, ensuring the feeding is delivered safely.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

Correct Answer is D

Explanation

A nurse is preparing to administer an enteral feeding via nasogastric tube. Identify the correct sequence the nurse should follow to initiate the feeding. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.)

Correct Answer is B,A,D,C

Explanation

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