A nurse is caring for a client who has not voided for 8 hr following the removal of an indwelling urinary catheter. Which of the following actions should be the nurse take first?
Provide assistance to bathroom.
Increase fluids.
Perform a bladder scan.
Insert a straight catheter.
The Correct Answer is C
A. Providing assistance to the bathroom is appropriate but should follow assessment and intervention for urinary retention.
B. Increasing fluids may be beneficial but does not address the immediate need to assess for urinary retention.
C. Performing a bladder scan is the first action to assess if the client has urine in the bladder and needs further intervention.
D. Inserting a straight catheter is a potential intervention but should be based on assessment findings from the bladder scan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Difficulty moving the upper extremities may be a result of the stroke but is not a direct complication of immobility.
B. Difficulty hearing some types of sounds is not a typical complication of immobility.
C. Stiffness in the lower extremities can occur but is less urgent than skin breakdown.
D. A reddened area over the sacrum indicates pressure injury, a common and serious complication of immobility that requires immediate attention.
Correct Answer is D
Explanation
A. Providing written materials with large print helps accommodate low literacy levels by enhancing readability and comprehension, but assessing the client’s ability to demonstrate the skill is more crucial to assess understanding.
B. Long teaching sessions can overwhelm clients with low literacy levels and may not improve understanding.
C. Using acronyms may confuse clients with low literacy levels if they are not familiar with medical abbreviations.
D. Asking the client to demonstrate the skill is important, since it allows the nurse to assess the client's comprehension and correct any mistakes during the learning process.
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