A patient's urinary catheter was removed 8 hours ago, and the patient has not voided.
What is the next nursing action?
Insert indwelling urinary catheter.
Position the patient on their left side.
Perform a bladder scan.
Instruct the patient to drink fluids.
The Correct Answer is C
Choice A rationale
Inserting an indwelling urinary catheter prematurely without assessing for bladder distension or attempting other less invasive interventions is not the first step. Catheterization carries risks like infection and trauma. A bladder scan provides objective data to guide further interventions.
Choice B rationale
Positioning the patient on their left side is not a primary intervention for urinary retention after catheter removal. While position can sometimes aid voiding, it is not a direct solution for a patient who has not voided for 8 hours and does not address the underlying issue of bladder fullness.
Choice C rationale
Performing a bladder scan is the most appropriate next nursing action. A bladder scan non-invasively measures the volume of urine in the bladder. If the bladder volume is significant (e.g., >200-400 mL, normal post-void residual is <50-100 mL), it indicates urinary retention, guiding further interventions.
Choice D rationale
Instructing the patient to drink fluids without assessing for bladder distension can exacerbate the problem if the patient is already experiencing retention. Increasing fluid intake without adequate outflow can lead to overdistension of the bladder, causing further discomfort and potential bladder damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.9"]
Explanation
Step 1: Calculate the volume to administer:. 35 mg ÷ (40 mg/mL) = 0.875 mL.
Step 2: Round to the nearest tenth:. 0.875 mL rounded to the nearest tenth is 0.9 mL. Final calculated answer: 0.9 mL.
Correct Answer is B
Explanation
Choice A rationale
The Glasgow Coma Scale (GCS) primarily assesses a patient's level of consciousness (LOC) by evaluating eye opening, verbal response, and motor response. While pupillary response is a crucial neurological assessment, it is a separate component and not directly incorporated into the GCS scoring system.
Choice B rationale
The Glasgow Coma Scale (GCS) is a standardized neurological assessment tool used to objectively evaluate a person's level of consciousness following a brain injury or other neurological insults. It assigns scores for eye opening, verbal response, and motor response, providing a quantitative measure of neurological impairment.
Choice C rationale
While motor response is a component of the GCS, the scale does not specifically test the detailed muscle strength of individual limbs, which is a separate neurological examination. The GCS assesses generalized motor commands, such as obeying commands or withdrawal from pain, rather than specific muscle power.
Choice D rationale
The Glasgow Coma Scale (GCS) does not directly assess memory loss. Memory assessment is a component of a more comprehensive cognitive examination, often performed as part of a mental status examination. The GCS focuses on immediate indicators of arousal and awareness.
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