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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Beginning ball squeezing exercises is not advisable immediately after a modified radical mastectomy. The client's arm on the affected side needs time to heal, and strenuous exercises can strain the surgical site, increase pain, and potentially disrupt the healing process.
Choice B rationale:
Wearing a bra with wire support is not recommended, especially in the early postoperative period. Underwire bras can irritate the surgical site and interfere with the healing process. Patients are usually advised to wear soft, non-underwire bras or special post-surgical bras designed for comfort and support.
Choice C rationale:
Avoiding the use of the affected arm for eating is the correct instruction. Protecting the surgical site and preventing strain is essential for proper healing. Encouraging the client to use the opposite arm for activities like eating can minimize movement in the affected area, reducing the risk of complications.
Choice D rationale:
Using deodorant under the affected arm is not recommended immediately after surgery. The surgical site needs to be kept clean and dry to prevent infection and promote healing. Deodorants, especially those containing chemicals or fragrances, can irritate the skin and increase the risk of complications. Patients are usually advised to avoid applying any products to the surgical area until it is fully healed.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should use the client's telephone number or another unique identifier, such as a medical record number or a unique identification code, to confirm the client's identity before administering medication. Using a telephone number or a unique identifier ensures accurate identification of the client and helps prevent medication errors.
Choice B rationale:
Place of birth is not a suitable identifier for confirming a client's identity. It does not provide specific and accurate information about the individual and may not be unique to the client.
Choice C rationale:
Driver license number is not a suitable identifier for confirming a client's identity. It may not be readily available in the healthcare setting, and not all clients have a driver's license. Using this identifier could lead to identification errors.
Choice D rationale:
Room number is not a suitable identifier for confirming a client's identity. Room numbers are not unique to individual clients and can change based on hospital assignments. Relying on room numbers can lead to confusion and medication errors.
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