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.
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Related Questions
Correct Answer is B
Explanation
A. Emphasizing the significance of the information may not address the cultural behavior of avoiding direct eye contact.
B. Continuing with the discussion respects the client's cultural behavior, as some cultures view direct eye contact as disrespectful.
C. Stopping the instructions to see what is on the floor may misunderstand the client's cultural behavior.
D. Moving closer for eye contact may make the client uncomfortable if their culture views direct eye contact as inappropriate.
Correct Answer is B
Explanation
A. Skin color is not the most critical parameter before a blood transfusion.
B. Temperature is important to monitor for baseline and the temperature should be monitored during infusion since an increase in temperature can indicate a transfusion reaction.
C. Fluid intake is relevant to assess overall hydration status but not the most critical before the transfusion.
D. Hemoglobin level is crucial to determine but it is not the most important data to obtain immediately before the infusion, as it does not change rapidly during the transfusion and does not indicate an ongoing reaction.
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