Exhibits

The nurse is planning care for the client.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition
Urinary Retention
The client's symptoms, including the urge to void, feeling "wet," and the bladder scan showing 600 mL of residual urine, suggest urinary retention. Urinary retention occurs when the bladder does not empty completely or at all, leading to a buildup of urine. This can happen postoperatively due to anesthesia effects, pain, or bladder dysfunction.
Actions to Take
• Request prescription for straight catheter

A straight catheter (intermittent catheterization) is used to drain the bladder and measure the amount of urine collected. It is often preferred over an indwelling catheter in cases of acute urinary retention where temporary relief and assessment of bladder function are needed.
•   Insert indwelling urinary catheter
An indwelling urinary catheter might be needed if urinary retention persists and is not relieved by other methods. It allows continuous drainage of urine and can be useful in managing acute or severe cases of urinary retention.
Parameters to Monitor
•   Amount of urine output
Monitoring urine output is crucial to evaluate how effectively the bladder is emptying after catheterization or other interventions. This helps in assessing whether the urinary retention is being resolved.
•   Residual urine
Checking residual urine with a bladder scanner can help determine how much urine remains in the bladder after voiding. Persistent high residual urine levels would indicate ongoing retention issues that need further intervention.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. This is the most crucial information to provide. A scleral buckling procedure is performed to repair a retinal detachment. Any signs of detachment recurrence are critical and should be reported immediately. Directly addresses the primary goal of the surgery.
B. While maintaining the head in a specific position is often recommended post-surgery, it's not the most critical information in this context. The focus should be on identifying potential complications. Not as critical as the other options.
C. Infection is a potential complication of any surgery, but it's not the primary concern immediately post-scleral buckling. Important but not the most critical information.
D. Ambulation is generally encouraged to prevent complications like pneumonia and deep vein thrombosis, but it's not a specific concern immediately post-scleral buckling. Not directly related to the procedure.

A. Decrease consumption of red meat and most seafood. B. Replace dietary table salt with salt substitutes. C. Limit use of mobility equipment to avoid muscle atrophy. D. Wrap joints with elastic bandage when swollen.

Correct Answer is A

Explanation

A. This instruction is particularly relevant for a client with gouty arthritis. Gout is a type of arthritis caused by elevated levels of uric acid in the blood, which can form crystals in the joints and cause severe pain and inflammation. Red meat and certain seafood are high in purines, which can increase uric acid levels and exacerbate gout symptoms.
B. This instruction might not be suitable for someone with hypertension, as many salt substitutes contain potassium. For a person with high blood pressure, excessive potassium can be harmful, especially if they are on certain medications or have kidney issues.
C. This advice may not be appropriate given the client's current inability to bear weight due to severe ankle pain. Limiting mobility equipment could lead to further physical complications. The focus should be on managing pain and inflammation to improve mobility rather than restricting the use of equipment.
D. While wrapping joints with an elastic bandage can help reduce swelling, it should be done with caution. Over-wrapping can lead to decreased circulation or additional pain. In cases of severe pain and swelling, other treatments such as rest, elevation, and ice may be more appropriate.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is scheduled for a scleral buckling procedure after previously having multiple laser coagulation procedures done for retinal tears. Which Information about the immediate postoperative period should the nurse provide this client?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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