An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample.After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

Give the client 8 ounces (236.5 mL) of water to drink.

Send the sample for laboratory evaluation.

Instruct the client to attempt to urinate again.

Evaluate the client for bladder distention.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Giving the client 8 ounces (236.5 mL) of water to drink may help in obtaining a urine sample, but it does not address the immediate concern of potential bladder distention.
Choice B rationale
Sending the sample for laboratory evaluation is not appropriate when the sample is insufficient. The nurse should first address the underlying issue of why the client could not provide an adequate sample.
Choice C rationale
Instructing the client to attempt to urinate again may not be effective if the client is experiencing bladder distention or another underlying issue preventing urination.
Choice D rationale
Evaluating the client for bladder distention is the most appropriate action. Bladder distention can cause lower abdominal discomfort and difficulty urinating. Assessing for distention can help determine if the client needs further intervention, such as catheterization.

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Correct Answer is B

Explanation

A. Document the presence of borborygmi.Loud, high-pitched, and almost continuous gurgling sounds can indicate borborygmi.However, the nurse should not immediately document without fully assessing all four quadrants to ensure a comprehensive evaluation of bowel sounds.

B. Auscultate the remaining quadrants.A complete assessment of bowel sounds involves auscultating all four quadrants to determine if the sounds are generalized, localized, or absent in other areas. This provides a more accurate assessment of the client’s gastrointestinal function.

C. Elevate the head of the client’s bed immediately.The client’s position does not typically affect bowel sounds, and elevating the head of the bed is unnecessary unless the client has difficulty breathing or other non-gastrointestinal concerns.

D. Use the bell of the stethoscope to auscultate again.Using the bell, which is intended for low-pitched sounds like bruits or heart murmurs, would not provide any additional relevant information.

A. Epigastric region. B. Umbilical region. C. Hypogastric region. D. Hypochondriac region.

Correct Answer is A

Explanation

Choice A rationale
Epigastric region is the correct answer. The epigastric region is the area of the abdomen located between the lower part of the ribcage and the navel (umbilicus). Pain localized in the middle section of the abdomen below the xiphoid process corresponds to the epigastric region.
Choice B rationale
The umbilical region is located around the navel (umbilicus) in the center of the abdomen. Pain in the umbilical region may be associated with conditions affecting the small intestine or structures around the navel, such as umbilical hernias.
Choice C rationale
The hypogastric region is located in the lower part of the abdomen, below the umbilical region. Pain in the hypogastric region typically corresponds to the lower abdomen, around the pubic bone.
Choice D rationale
The hypochondriac regions are located on each side of the upper abdomen, beneath the ribs. Pain in the hypochondriac region may be associated with conditions affecting the liver, gallbladder, or spleen.

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An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample.After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high-pitched almost continuous gurgling in two quadrants. Which action should the nurse implement first?

Correct Answer is B

Explanation

A client reports experiencing stomach pain and it is localized in the middle section of the abdomen below the xiphoid process. The nurse should describe the pain as occurring in which region of the abdomen?

Correct Answer is A

Explanation

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