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.

Evaluate the client for bladder distention.

Instruct the client to attempt to urinate again.

Send the sample for laboratory evaluation.

Answer and Explanation

The Correct Answer is B

A. Giving the client water to drink might help produce more urine, but it does not address the immediate issue of potential bladder distention, which can cause discomfort and urinary retention.
B. Evaluating the client for bladder distention is the priority action. The symptoms of lower abdominal discomfort and difficulty urinating suggest possible urinary retention, which could be due to an enlarged prostate or other obstructive issues. Assessing for bladder distention will help determine if the bladder is full and if further interventions, such as catheterization, are needed.
C. Instructing the client to try urinating again may not be effective if the client is experiencing urinary retention, and it doesn't address the underlying issue.
D. Sending the few drops of urine for evaluation could provide some information but does not address the potential problem of bladder distention or retention.

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Correct Answer is ["A","C","D"]

Explanation

A. Use a warmed bell of the stethoscope and place it lightly over the four quadrants
Using a warmed stethoscope helps to avoid discomfort for the patient and ensures better transmission of sound. The bell of the stethoscope is effective for detecting low-pitched sounds such as bowel sounds. Lightly placing the stethoscope over the four quadrants of the abdomen allows for thorough assessment of bowel sounds in each area.
B. Place the stethoscope in the ears with the earpieces pointing towards the ears
While this is a standard practice for proper use of a stethoscope to ensure correct sound conduction, it is not specific to assessing bowel sounds. This action is important for accurate auscultation but does not directly relate to the technique of assessing bowel sounds.
C. Turn the suction off while auscultating
Turning off the nasogastric tube suction is crucial because suction noise can interfere with the assessment of bowel sounds. Clear and accurate auscultation of bowel sounds requires a quiet environment to avoid misinterpretation of sounds. Therefore, it is important to turn off any equipment that might create noise during the assessment.
D. Auscultate at least 5 minutes of continuous listening before determining that bowel sounds are absent
Auscultating for a minimum of 5 minutes is essential to confirm the absence of bowel sounds. This extended duration helps in making an accurate assessment, as bowel sounds can be intermittent, and it ensures that transient sounds are not missed. This step is critical before concluding that bowel sounds are absent.
E. Palpate the abdomen before auscultating
Palpating the abdomen before auscultating can alter bowel sounds due to the manipulation of the intestines, potentially leading to inaccurate assessment. It is recommended to auscultate first to avoid affecting the natural bowel sounds before physical examination. Palpation should be done after auscultation to assess for any physical abnormalities or tenderness.

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

Correct Answer is A

Explanation

A. The epigastric region is located in the upper central part of the abdomen, just below the xiphoid process. Pain in this area is often associated with conditions affecting the stomach, such as gastritis or peptic ulcers.
B. The umbilical region is the central part of the abdomen around the navel and does not correspond to the area described by the client.
C. The hypochondriac regions are located on the upper sides of the abdomen, near the lower ribs, and are not relevant to the area described.
D. The hypogastric region is the lower central part of the abdomen, below the umbilicus, and is unrelated to the client's described pain.

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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

Exhibits The nurse is assessing the client for bowel sounds. Which intervention(s) would be indicated to assess bowel sounds? Select all that apply.

Correct Answer is ["A","C","D"]

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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