The nurse is assessing a client lying in a supine position and finds that the client's bladder is palpable and rises above the symphysis pubis, but it is not close to the umbilicus.
What will the nurse document?
The bladder is distended.
The bladder is empty.
The bladder is cancerous.
The bladder is normal.
The Correct Answer is A
Choice A rationale
A palpable bladder that rises above the symphysis pubis is a clear clinical sign of bladder distention. Normally, an empty or minimally filled bladder is located deep within the pelvic cavity and cannot be felt through the abdominal wall. When urine volume exceeds approximately 200 to 400 mL, the bladder expands upward into the hypogastric region, becoming palpable as a firm, rounded mass above the pubic bone.
Choice B rationale
If the bladder were empty, it would remain behind the symphysis pubis and would not be palpable during a physical assessment of the abdomen. An empty bladder contains very little volume and does not extend into the abdominal cavity. Therefore, finding a palpable mass in this location directly contradicts the conclusion that the bladder is empty. Normal residual volume is usually less than 50 mL.
Choice C rationale
While a bladder tumor could potentially cause a palpable mass, distention due to urinary retention is a much more common and immediate cause of a palpable bladder. A nurse cannot diagnose cancer based solely on palpation; such a conclusion requires diagnostic imaging, cystoscopy, and biopsy. Documenting the bladder as cancerous based only on a physical exam would be outside the nurse's scope and medically premature.
Choice D rationale
A palpable bladder above the symphysis pubis is not considered a normal finding in a healthy, recently voided adult. While it is a common finding in patients with urinary retention, it indicates an abnormal accumulation of urine that requires intervention or further monitoring. A normal bladder should not be felt until it is significantly full, and even then, it suggests the patient may need to void.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Agglutinin refers to an antibody that causes the clumping of particles, such as bacteria or red blood cells. While it is a critical component of blood typing and cross-matching to ensure compatibility, it does not describe a method of blood collection or a specific type of transfusion. Understanding agglutination is vital for preventing hemolytic transfusion reactions, but it is a biochemical process rather than a procedural category for donating blood.
Choice B rationale
Autologous transfusion involves the collection and subsequent reinfusion of a client's own blood. This is often planned weeks before an elective surgery to eliminate the risk of transfusion-transmitted infections and alloimmunization, which occurs when a patient develops antibodies against foreign blood cells. Because the blood is a perfect genetic match, the risk of hemolytic reactions is virtually non-existent, making it the safest option for patients who can pre-donate.
Choice C rationale
Anions are negatively charged ions, such as chloride or bicarbonate, that play a fundamental role in maintaining acid-base balance and osmotic pressure within the body. While electrolytes are present in blood products, the term anion has no relation to the source of the blood used for transfusion. It is a chemical classification used in the study of fluid and electrolyte management rather than a term for blood donation styles.
Choice D rationale
Active transport is a biological process where molecules move across a cell membrane from an area of lower concentration to an area of higher concentration, requiring the expenditure of cellular energy in the form of adenosine triphosphate. This is a microscopic physiological mechanism used by cells to maintain gradients. It does not refer to the clinical practice of moving blood from a donor or a storage unit into a patient's vascular system.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Perineal hygiene is a critical component of infection control because the accumulation of fecal matter or secretions near the urethral meatus facilitates the migration of pathogenic bacteria up the catheter lumen. Proper cleansing, especially after bowel movements, reduces the microbial load and prevents the colonization of organisms like Escherichia coli. Maintaining a clean environment around the insertion site is a standard evidence based practice for reducing the incidence of catheter associated urinary tract infections in hospitalized patients.
Choice B rationale
Adequate hydration is vital because it promotes a steady flow of urine, which mechanically flushes the bladder and the urinary catheter. This continuous flushing action helps prevent the stasis of urine, which can otherwise serve as a medium for bacterial proliferation. Unless the patient has a medical contraindication such as congestive heart failure or renal failure, increasing fluid intake remains a primary non pharmacological intervention to maintain urinary tract health and prevent biofilm formation on the device.
Choice C rationale
Maintaining the drainage bag at or above the level of the bladder is incorrect and dangerous because it allows for the reflux of stagnant urine from the bag or tubing back into the bladder. Gravity should always be utilized to ensure one way flow away from the patient. Backflow carries contaminated urine and accumulated bacteria directly into the sterile bladder environment, significantly increasing the risk of infection. The bag should always be kept below the level of the bladder.
Choice D rationale
The urinary tract is naturally sterile, and the introduction of a foreign body like a catheter requires a strict aseptic technique to prevent the introduction of exogenous pathogens. Breaches in sterility during insertion are a leading cause of immediate post procedure infections. Using sterile gloves, drapes, and antiseptic solutions ensures that the initial environment remains uncontaminated, which is essential for preventing the early onset of healthcare associated infections in vulnerable or immunocompromised patients.
Choice E rationale
The application of powders to the perineal area is contraindicated in catheter care because powder can cake, trap moisture, and provide a substrate for bacterial or fungal growth. Additionally, particles from the powder can irritate the urethral meatus or become a source of crusting that makes hygiene more difficult. It does not provide a protective barrier and may lead to skin breakdown or inflammatory responses, which ultimately compromises the integrity of the primary defense against ascending infections.
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