A nurse is caring for a female client who requires bed rest and reports difficulty urinating into a bedpan.
Which of the following actions should the nurse take?

Turn on the faucets in the client's sink.

Tell the client to gently stroke her lower abdomen.

Instruct the client to lean slightly backward.

Pour cool water over the client's perineum.

Answer and Explanation

The Correct Answer is B

Choice B rationale:

Instructing the client to gently stroke her lower abdomen is the appropriate action in this situation. Gentle stroking or tapping on the lower abdomen can stimulate the bladder reflex and promote urination. This technique can help clients who have difficulty voiding, especially when using a bedpan. It encourages relaxation of the pelvic muscles, making it easier for the client to urinate.

Choice A rationale:

Turning on the faucets in the client's sink is not a recommended action for promoting urination. While the sound of running water can sometimes trigger the need to urinate, it may not be effective for every individual. Moreover, this action may not be practical or feasible in all healthcare settings.

Choice C rationale:

Instructing the client to lean slightly backward is not an appropriate action for promoting urination. Leaning backward can put pressure on the bladder, which may make it more challenging for the client to urinate. Encouraging relaxation and using techniques like gentle abdominal stroking are more effective in this situation.

Choice D rationale:

Pouring cool water over the client's perineum is not a recommended action for promoting urination. While some individuals find warm water soothing and relaxing, pouring cold water may cause discomfort and stress, making it even more difficult for the client to urinate. Gentle stimulation and relaxation techniques are generally more effective.

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Correct Answer is C

Explanation

a. The last time the provider evaluated the client:This information helps the receiving nurse stay updated on the client's clinical status and recent provider recommendations.
b. The client's most recent ventilator settings:The client's most recent ventilator settings (B) would no longer be relevant if the client has been successfully weaned off mechanical ventilation.
c. The time of the client's last dose of pain medication:This helps manage the client's pain effectively and prevent potential withdrawal symptoms.

d. This information is not clinically relevant for the next nurse’s shift. While the frequency of call button use may reflect a client's needs or comfort level, it is not a priority for safe, evidence-based clinical care and does not impact the client’s medical treatment or condition.

A. "Keep mobile phones 4 inches from the pacemaker generator.” B. "Limit strenuous physical activity for 8 weeks.” C. "Check your pulse rate for 30 seconds at different times throughout the day.” D. "Expect to have intermittent, prolonged hiccups.”

Correct Answer is A

Explanation

Choice A rationale:

The nurse should include the information about keeping mobile phones at least 4 inches away from the pacemaker generator in the educational materials for the client. This is because mobile phones emit electromagnetic signals that could interfere with the functioning of the pacemaker. Maintaining a safe distance helps prevent electromagnetic interference, ensuring the pacemaker functions properly without any disruptions. It's crucial for the client to be aware of this to prevent potential complications and ensure the pacemaker's effectiveness.

Choice B rationale:

Limiting strenuous physical activity for 8 weeks is not a necessary precaution for a client with a new pacemaker unless specifically advised by the healthcare provider. Patients with pacemakers are often encouraged to resume normal activities after the procedure, with the understanding that they should listen to their bodies and avoid activities that cause discomfort or strain. There is no standard guideline suggesting an 8-week restriction on strenuous physical activity for all patients with new pacemakers.

Choice C rationale:

Checking the pulse rate for 30 seconds at different times throughout the day is a general health practice and not specifically related to the presence of a pacemaker. While monitoring heart rate is essential for overall health, it is not a pacemaker-specific guideline that must be included in the educational materials for a client with a new pacemaker.

Choice D rationale:

Expecting to have intermittent, prolonged hiccups is not relevant information for a client with a new pacemaker. Hiccups are a common physiological phenomenon and are not influenced by the presence of a pacemaker. Including this information in the educational materials would be irrelevant and potentially confusing for the client.

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A nurse is caring for a female client who requires bed rest and reports difficulty urinating into a bedpan.Which of the following actions should the nurse take?

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A nurse is caring for a female client who requires bed rest and reports difficulty urinating into a bedpan.
Which of the following actions should the nurse take?