A nurse is caring for a male patient experiencing urinary retention. Which action should the nurse take first?
Limit fluid intake.
Insert a urinary catheter.
Assist to a standing position.
Ask for a diuretic medication.
The Correct Answer is C
A. Limit fluid intake:
This can worsen retention by reducing the urge to void. Not appropriate unless fluid overload is present.
B. Insert a urinary catheter:
This may be required, but non-invasive interventions like position change should be tried first, especially if there's no acute distress.
C. Assist to a standing position:
For male patients, standing often promotes natural voiding by utilizing gravity and familiarity of position. Least invasive and most appropriate initial step.
D. Ask for a diuretic medication:
Diuretics increase urine production but do not resolve urinary retention. They may worsen bladder distention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
A. Growing urine cultures for up to 12 hours:
Nurses do not grow cultures; lab personnel handle this. The nurse’s role is collection and proper transport of specimens.
B. Labeling all specimens with date, time, and initials:
Correct labeling ensures proper identification and prevents errors in diagnosis and treatment.
C. Allowing the patient adequate time and privacy to void:
Respecting patient privacy encourages accurate specimen collection and maintains dignity.
D. Wearing gown, gloves, and mask for all specimen handling:
Gloves are necessary, but gowns and masks are not required unless splashing or isolation precautions are involved.
E. Transporting specimens to the laboratory in a timely manner:
Delays in transport can lead to contamination or degradation of the sample, affecting test accuracy.
F. Collecting the specimen from the drainage bag of an indwelling catheter:
Urine from the drainage bag is not sterile and is not appropriate for culture. It may yield inaccurate results
Correct Answer is C
Explanation
A. An 8-year-old male undergoing anesthesia for a tonsillectomy:
This child likely has no anatomical issues. A straight catheter would typically suffice for short-term use.
B. A 24-year-old female who is going into labor:
Females typically have a short urethra; a standard catheter is appropriate.
C. A 56-year-old male admitted for bladder irrigation:
Coudé catheters are curved-tipped and designed for males with prostatic hypertrophy or urethral stricture, which is common in older males. This is the correct use.
D. An 86-year-old female admitted for a urinary tract infection:
There is no indication of urethral obstruction or prostatic issues-Coudé not necessary.
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