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 B
Explanation
A. Respiratory therapist: While helpful in respiratory management, they do not assess swallowing ability.
B. Speech therapist: A speech-language pathologist evaluates swallowing function and recommends dietary textures and techniques to reduce aspiration risk.
C. Physical therapist: Focuses on mobility and strength, not swallowing.
D. Dentist: May manage oral health, but does not evaluate or treat dysphagia.
Correct Answer is ["A","D"]
Explanation
A. Voiding pattern: Monitoring the frequency, amount, and timing of urination helps identify retention issues. Infrequent or small-volume voiding can indicate retention.
B. Dribbling of urine: Dribbling can occur when the bladder is full and cannot empty completely, leading to overflow incontinence, a sign of retention.
C. Color of the urine: While urine color may indicate hydration or infection, it is not a specific indicator of urinary retention.
D. Bladder distension: A full, distended bladder upon palpation or percussion suggests urinary retention.
E. Proteinuria: Protein in urine indicates possible renal disease, not urinary retention.
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