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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. "Consume a low-fiber diet.": A high-fiber diet promotes bowel movement regularity.

B. "Increase your daily fluid intake.": Fluids help soften stool and promote bowel movements.

C. "Reduce your daily activity.": Physical activity stimulates peristalsis and helps relieve constipation.

D. "Try to defecate at different times of the day.": Establishing a regular time (especially after meals) promotes bowel training.

A. Symphysis Pubis B. Umbilicus C. Brachial Artery D. Xiphoid process

Correct Answer is D

Explanation

A. Symphysis pubis: This is not used in NG tube measurement; it’s used in bladder catheterization or pelvic assessments.

B. Umbilicus: Not part of the measurement for NG tube insertion.

C. Brachial artery: Not relevant to NG tube placement.

D. Xiphoid process: This is the correct anatomical landmark used to estimate the proper length for NG tube placement—from the nose to the ear to the xiphoid process ensures the tube reaches the stomach.

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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?

Nursing Test Bank

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