After surgery, a post-operative patient has not urinated for 8 hours.
Where should the nurse check for bladder distention?
Palpate between the symphysis pubis and the umbilicus
Palpate over the costovertebral region of the flank
Palpate in the left lower quadrant of the abdomen
Palpate between ribs 11 and 12 and the umbilicus
The Correct Answer is A
Anatomy: The bladder is a hollow, muscular organ located in the lower abdomen, just behind the pubic bone. It stores urine until it is emptied through urination. The area between the symphysis pubis (the joint where the two pubic bones meet) and the umbilicus (belly button) is directly over the bladder, making it the most appropriate place to palpate for bladder distention.
Signs of bladder distention: When the bladder is distended, it can be felt as a firm, round mass in the lower abdomen. The patient may also experience discomfort, pressure, or an urge to urinate.
Nursing assessment: Palpation is a key nursing assessment skill used to evaluate the size, shape, and position of organs within the abdomen. In this case, palpation helps the nurse to determine if the bladder is distended and to assess the severity of the distention.
Clinical significance: Bladder distention can occur for a variety of reasons, including:
Postoperative urinary retention due to anesthesia or pain medications
Urinary tract obstruction (e.g., from a kidney stone or enlarged prostate)
Neurological conditions that affect bladder function (e.g., spinal cord injury, multiple sclerosis)
Dehydration
Certain medications (e.g., diuretics, anticholinergics)
Prompt intervention: Bladder distention can lead to complications such as urinary tract infections, kidney damage, and discomfort. It's important for the nurse to identify and address bladder distention promptly to prevent these complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Brown or black urine is not a typical observation associated with Levodopa use. It can indicate other potential causes, such as: Dehydration
Liver disease
Rhabdomyolysis (muscle breakdown)
Certain medications like metronidazole or iron supplements
Hematuria (blood in the urine)
It's essential to rule out these conditions if brown or black urine is observed.
Choice C rationale:
Green or blue-green urine is also not common with Levodopa. It can be caused by:
Medications like amitriptyline, indomethacin, propofol, or methylene blue
Certain food dyes
Urinary tract infections caused by Pseudomonas bacteria
Familial benign hypercalcemia (a rare genetic condition)
Choice D rationale:
Blood-tinged urine (hematuria) is not a direct effect of Levodopa. It can signal underlying urinary tract issues, such as: Infections
Kidney stones
Bladder or kidney tumors
Trauma to the urinary tract
Strenuous exercise
Choice B rationale:
Orange or orange-red urine is the most common observation in patients taking Levodopa. This discoloration is due to: Breakdown of Levodopa into dopamine and other metabolites
These metabolites can impart an orange or reddish hue to the urine
The color intensity may vary depending on dosage and individual metabolism
It's generally harmless and doesn't require medical intervention
However, it's essential to inform healthcare providers about any urine color changes to ensure proper monitoring and rule out other potential causes.
Correct Answer is C
Explanation
Rationale for Choice A:
Sims' position is a side-lying position with the lower arm and leg flexed and the upper arm and leg extended. It is not ideal for bladder scanning because it can displace the bladder and potentially lead to inaccurate readings. While it can be used for other purposes, such as inserting rectal suppositories or performing vaginal exams, it's not the optimal choice for bladder scanning.
Rationale for Choice B:
Dorsal recumbent position is a supine position with the knees bent and feet flat on the bed. While it provides some exposure of the bladder, it may not fully visualize the entire bladder due to potential compression from the abdominal contents. This can also result in inaccurate readings.
Rationale for Choice D:
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 it can cause the bladder to shift upward and out of the optimal scanning range. It's typically used for respiratory comfort and procedures involving the head and upper body.
Rationale for Choice C:
Supine position is the best position for bladder scanning because it allows for the most accurate visualization of the bladder. In this position, the patient lies flat on their back with their legs extended. This position allows the bladder to rest naturally in the pelvic cavity, ensuring optimal positioning for the bladder scanner to capture a clear image and provide an accurate measurement of bladder volume. It also promotes patient comfort and relaxation during the procedure.
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