A nurse is caring for a client who has tolerated a clear liquid diet but not voided for 8 hours following surgery. Which of the following actions should the nurse take first?
Provide assistance to bathroom.
Perform a bladder scan
Offer the client fluids.
Insert an indwelling urinary catheter.
The Correct Answer is B
A. Provide assistance to bathroom: This is appropriate if the client feels the urge but not the priority when there’s a concern for urinary retention.
B. Perform a bladder scan: This is the first step in assessment to determine if the bladder is full and retention is present before taking further action.
C. Offer the client fluids: Fluids help with hydration but not necessarily with retention if the bladder is already full.
D. Insert an indwelling urinary catheter: This is an invasive intervention and should only be done after confirming urinary retention with a scan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E","G"]
Explanation
Client will not look at stoma / not interested in learning: Indicates emotional distress, potential body image disturbance, or denial—requires psychosocial support and gradual introduction to care.
Skin surrounding stoma is reddened and has small open areas: Indicates peristomal skin breakdown, requiring intervention to prevent infection and promote healing.
Findings like “stoma is red” and “brown liquid stool” are normal and expected for an ileostomy.
Correct Answer is D
Explanation
A. Rigid abdomen: A rigid abdomen suggests peritonitis or another surgical emergency, not dehydration.
B. Decreased bowel sounds: Diarrhea usually causes hyperactive bowel sounds, not decreased.
C. Hypothermia: Clients with diarrhea or fluid loss usually present with normal or elevated temperatures, especially if infection is involved.
D. Dehydration: Diarrhea and limited fluid intake lead to dehydration, which presents with dry mucous membranes, increased thirst, tachycardia, and concentrated urine.
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