A nurse is using a bladder scanner to assess the bladder volume of a client with urinary frequency. In which position would the nurse place the client?
Sims’ position
Dorsal recumbent position
Supine position
High Fowler’s position
The Correct Answer is B
Choice A rationale:
Sims' position is a side-lying position with the lower leg flexed and the upper leg extended. It is not ideal for bladder scanning because it can compress the bladder and make it difficult to obtain an accurate reading.
Additionally, in Sims' position, the bladder may not be fully accessible to the scanner, as it may be partially obscured by the upper thigh.
Choice B rationale:
Dorsal recumbent position is the optimal position for bladder scanning. In this position, the client lies flat on their back with their knees bent and their feet flat on the bed. This position allows for:
Full exposure of the bladder, making it easily accessible to the scanner.
Relaxation of the abdominal muscles, which can help to ensure an accurate reading.
A comfortable position for the client, promoting cooperation and reducing the likelihood of movement that could interfere with the scan.
Choice C rationale:
Supine position is a similar position to dorsal recumbent, but with the legs fully extended. While it is possible to perform a bladder scan in this position, it is not as ideal as dorsal recumbent because:
The extended legs can place some tension on the abdominal muscles, potentially affecting bladder position and the scan's accuracy.
The client may find this position less comfortable, leading to restlessness and potential movement that could interfere with the scan.
Choice D rationale:
High Fowler's position is a semi-sitting position with the head of the bed elevated at a 45- to 60-degree angle. This position is not suitable for bladder scanning because:
Gravity can pull the bladder downwards, making it difficult to visualize and measure accurately.
It can be challenging to maintain proper positioning of the scanner on the abdomen in this position, potentially leading to inaccurate readings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Anxiety is a valid concern for any client undergoing surgery, but it is not the priority nursing diagnosis in this case. The client's risk for infection is more pressing due to the following factors:
Large surgical wound: Wounds provide a potential entry point for pathogens.
Obesity: Excess adipose tissue can impair wound healing and increase the risk of infection.
Corticosteroid medications: These medications suppress the immune system, making it more difficult for the body to fight off infection.
Choice B rationale:
Self-care Deficit may be a concern if the client has difficulty caring for the surgical wound or maintaining hygiene due to obesity. However, it is not the priority diagnosis in this case. The focus should be on preventing infection, which would also help to address any self-care deficits.
Choice D rationale:
Risk for Imbalanced Nutrition is a relevant diagnosis for a client who has had colon surgery, as they may experience changes in appetite, digestion, or absorption of nutrients. However, it is not the priority diagnosis in this scenario. Preventing infection is crucial to ensure proper wound healing and overall recovery.
Choice C rationale:
Risk for Infection is the priority nursing diagnosis for this client due to the following risk factors: Large surgical wound: The wound provides a potential entry point for bacteria and other pathogens.
Obesity: Excess adipose tissue can impair wound healing by reducing blood flow to the area and increasing the risk of wound dehiscence (separation of wound edges). This can create a favorable environment for bacterial growth.
Corticosteroid medications: These medications suppress the immune system, making it more difficult for the body to fight off infection.
Nursing interventions to address Risk for Infection:
Assess the wound regularly for signs of infection, such as redness, swelling, warmth, pain, or purulent drainage. Implement strict aseptic technique when caring for the wound.
Teach the client about proper wound care and hygiene practices.
Monitor the client for signs of systemic infection, such as fever, chills, or malaise. Administer antibiotics as prescribed.
Encourage adequate nutrition and hydration to support wound healing.
Collaborate with the healthcare team to manage the client's risk factors for infection.
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale:
Oral route anesthetic blocks are not considered regional anesthesia. They are a form of systemic anesthesia, meaning they affect the entire body.
Oral anesthetics are absorbed through the gastrointestinal tract and distributed throughout the bloodstream to reach their target sites in the central nervous system.
They produce a general depressant effect on the brain and spinal cord, leading to sedation, unconsciousness, and analgesia. Examples of oral anesthetics include benzodiazepines, barbiturates, and propofol.
Choice B rationale:
Inhalation anesthetic blocks are also a form of systemic anesthesia.
They are administered through inhalation of vaporized gases or volatile liquids.
These anesthetics rapidly cross the alveolar-capillary membrane in the lungs and enter the bloodstream, where they are transported to the brain and other tissues.
They produce a dose-dependent depression of the central nervous system, resulting in loss of consciousness, analgesia, and muscle relaxation.
Examples of inhalation anesthetics include nitrous oxide, sevoflurane, and isoflurane.
Choice C rationale:
Spinal anesthetic blocks are a type of regional anesthesia that involves injecting a local anesthetic directly into the subarachnoid space of the spinal cord.
This blocks nerve transmission in the spinal cord, resulting in loss of sensation and motor function in the lower half of the body.
Spinal anesthesia is commonly used for surgeries below the waist, such as cesarean deliveries, hip replacements, and knee surgeries.
Choice D rationale:
Epidural anesthetic blocks are another type of regional anesthesia that involves injecting a local anesthetic into the epidural space, which is the area surrounding the spinal cord.
This blocks nerve transmission in the spinal nerves, resulting in loss of sensation and motor function in a specific region of the body.
Epidural anesthesia is commonly used for labor and delivery, as well as for surgeries on the abdomen, pelvis, and lower extremities.
Choice E rationale:
Nerve anesthetic blocks (also known as peripheral nerve blocks) involve injecting a local anesthetic around a specific nerve or group of nerves.
This blocks nerve transmission in the targeted area, resulting in loss of sensation and motor function in a specific part of the body.
Nerve blocks can be used for a variety of surgical procedures, as well as for pain management.
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