A nurse is caring for a client who is 6 hr postoperative following abdominal surgery and is having difficulty voiding. Which of the following actions should the nurse take?
Allow the client to hear running water while attempting to void.
Provide the client a bedpan while lying supine.
Encourage fluid intake up to 1,000 mL daily.
Insert an indwelling urinary catheter and connect it to gravity drainage.
The Correct Answer is A
A. At 6 hours postoperative, difficulty voiding is common due to anesthesia effects and pain. The nurse should begin with noninvasive measures to stimulate urination. Hearing running water can help trigger the micturition reflex and promote voiding safely.
B. Lying supine may make it more difficult for the client to void. Sitting upright or ambulating to the bathroom may be more effective.
C. This is inadequate fluid intake; normal intake is usually 2,000–3,000 mL/day unless restricted. Furthermore, this does not directly address the immediate difficulty voiding.
D. Catheterization should be considered only after other interventions to promote voiding have been attempted and failed, as it carries the risk of infection and discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A transfer belt should be removed after the transfer is completed, as it can cause skin irritation or pressure ulcers if left in place for too long.
B. Footplates should be raised during transfer to prevent tripping, then lowered once the client is seated.
C. This ensures safety, as the larger rear wheels enter first, preventing the smaller front wheels from catching on the elevator threshold.
D. Positioning the client so their weight is shifted forward can make the transfer more difficult and increase the risk of falling.
Correct Answer is A
Explanation
A. Obtaining the client's type and cross-match is the first action the nurse should take because it ensures that the client will have compatible blood available for transfusion if needed during surgery.
B. This is important but should only be done after obtaining the client’s type and cross-match.
C. This should be done after obtaining the client’s type and cross-match.
D. While an incident report may be necessary, the immediate priority is to address the oversight and ensure patient safety.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.