The nurse is caring for a male client with a history of benign prostatic hyperplasia (BPH) who reports being unable to void any urine for the last 8 hours.
Which of the following actions should the nurse take first?
Notify a urologist to insert a metal catheter with a prostatic curve.
Prepare the client to have a cystostomy performed.
Insert an indwelling urethral catheter.
Notify the health care provider to discuss surgical options with the client.
The Correct Answer is C
Choice A rationale
Metal catheters with prostatic curves are used in challenging cases of urinary retention caused by BPH. However, these catheters are not the first-line intervention due to their specialized nature and the risk of injury. Less invasive measures should be tried first.
Choice B rationale
Cystostomy, a surgical procedure that creates a suprapubic urinary drainage site, is reserved for severe cases of urinary retention where catheterization fails. It is not the initial step due to its invasive nature and requirement for surgical expertise.
Choice C rationale
Inserting an indwelling urethral catheter is the first-line action for managing acute urinary retention associated with BPH. It provides immediate bladder decompression, relieves discomfort, and reduces risks of complications like hydronephrosis or bladder rupture.
Choice D rationale
Discussing surgical options addresses the long-term management of BPH but does not resolve acute urinary retention. Interventions like catheterization should first alleviate symptoms before evaluating the need for definitive surgical treatment. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
Choice A rationale
Malaise is more associated with systemic conditions, such as upper urinary tract infections or generalized illness, rather than isolated lower urinary tract infections. Lower UTIs tend to present with localized urinary symptoms rather than systemic effects.
Choice B rationale
Chills suggest systemic involvement and are characteristic of pyelonephritis or upper urinary tract infections. Lower UTIs typically do not produce systemic signs like chills, as the infection is confined to the bladder and urethra.
Choice C rationale
Dysuria is a classic symptom of lower UTIs. It results from inflammation of the bladder mucosa due to the presence of pathogenic organisms. The irritation of the urinary tract leads to painful or difficult urination, confirming the diagnosis of lower UTI.
Choice D rationale
High fever, like chills, is indicative of upper urinary tract infections, such as pyelonephritis. Lower UTIs are generally afebrile, presenting more with localized urinary symptoms rather than systemic manifestations.
Choice E rationale
Urinary frequency is another hallmark symptom of lower UTIs, caused by bladder irritation. The infection leads to an increased urge to urinate, even when little urine is produced. This symptom is specific to lower UTIs and supports the diagnosis when present.
Correct Answer is C
Explanation
Choice A rationale
Constant erythema and warmth in the legs are indicative of venous insufficiency due to stagnant blood flow. PAD typically presents with cool, pale extremities as a result of reduced arterial perfusion.
Choice B rationale
Discomfort typically worsens when legs are elevated in PAD because elevation further impairs blood flow, causing ischemic pain. Relief is more commonly achieved when the legs are in a dependent position, aiding perfusion.
Choice C rationale
Pain during exercise, termed intermittent claudication, occurs due to insufficient oxygen delivery to muscles. Rest alleviates symptoms as oxygen demand decreases. This hallmark feature distinguishes PAD from other circulatory disorders.
Choice D rationale
Peripheral pulses in PAD are generally diminished or absent, reflecting compromised arterial blood flow. Bounding pulses would suggest conditions such as aortic regurgitation or hyperdynamic states, not PAD.
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