A nurse is caring for a client who is postpartum and has urinary retention. Which of the following actions should the nurse take?
Administer a prescribed diuretic.
Apply an ice pack to the client's perineum.
Place the client's hands in warm water.
Insert an indwelling catheter.
The Correct Answer is C
A. Administer a prescribed diuretic: Diuretics are used to promote urine production but are not the first-line intervention for postpartum urinary retention. They can cause fluid and electrolyte imbalances and do not address the underlying issue of bladder atony or difficulty initiating urination.
B. Apply an ice pack to the client's perineum: Ice packs are used to reduce perineal swelling and provide comfort after vaginal delivery, but they do not facilitate bladder emptying. Applying ice may actually inhibit urination by causing local vasoconstriction and decreased sensation.
C. Place the client's hands in warm water: Submerging the client’s hands in warm water can stimulate the micturition reflex via the parasympathetic nervous system. This noninvasive measure promotes relaxation of the urethral sphincter and facilitates spontaneous voiding, making it an appropriate first intervention for postpartum urinary retention.
D. Insert an indwelling catheter: Catheterization is effective for relieving acute urinary retention but is invasive and carries a risk of infection. It is reserved for cases when noninvasive measures, such as bladder scanning, positioning, or warm water stimulation, have failed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hypertension: Clozapine is more commonly associated with orthostatic hypotension due to its alpha-adrenergic blocking effects rather than hypertension. Clients may experience dizziness or lightheadedness when standing, especially during initiation or dose titration. Hypertension is not a hallmark adverse effect requiring focused teaching.
B. Agranulocytosis: Clozapine carries a well-known risk of agranulocytosis, a severe reduction in neutrophils that significantly increases susceptibility to infections. Clients require regular monitoring of absolute neutrophil count (ANC) through mandated blood tests. Early recognition of signs such as fever or sore throat is critical, making this the most important adverse effect.
C. Urinary retention: Although clozapine has anticholinergic properties that can contribute to urinary retention, this is not among the most serious or high-priority adverse effects associated with the medication. It may require monitoring but does not carry the same level of risk as hematologic complications.
D. Weight loss: Clozapine is more commonly associated with weight gain and metabolic syndrome, including increased appetite, hyperglycemia, and dyslipidemia. Weight loss is not an expected adverse effect and would not be a primary focus of client education for this medication.
Correct Answer is D
Explanation
A. “Polyuria can be caused by using antidepressants.": Antidepressants are not a direct cause of polyuria. Some medications may have anticholinergic or diuretic side effects that affect urinary patterns, but they are more likely to cause urinary retention or frequency rather than true polyuria, which is defined as excessive urine output exceeding 2,500–3,000 mL per day.
B. "Polyuria can be caused by enlargement of the prostate gland.": Prostate enlargement usually causes urinary retention, hesitancy, or frequency due to obstruction, not polyuria. Polyuria involves increased urine volume from conditions affecting urine production or osmoregulation, rather than obstruction.
C. "Polyuria can be caused by trauma to the lower urinary tract.": Trauma to the lower urinary tract may cause hematuria, dysuria, or retention, but it does not typically increase urine output. Polyuria results from renal or systemic factors that increase urine production, not from physical injury to the bladder or urethra.
D. "Polyuria can be caused by drinking too much fluid.": Excessive fluid intake can lead to polyuria, known as “psychogenic polydipsia” when voluntary. Increased fluid intake raises urine output as the kidneys attempt to maintain fluid and electrolyte balance, making this medically accurate explanation for polyuria.
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