The nurse is caring for a postoperative client who reports difficulty urinating. The client does not have a urinary catheter in place. Which nursing action(s) are most appropriate at this time? Select all that apply.

Run water to assist in the let-down reflex.

Measure urinary output.

Assist to the bathroom.

Place a urinary catheter.

Assist the client to stand.

Answer and Explanation

Correct Answer : A,C,E

A. Run water to assist in the let-down reflex: The sound of running water can stimulate the parasympathetic nervous system, triggering the urge to void. It’s a noninvasive and effective first-line intervention. This helps reduce urinary retention without immediate need for catheterization.
B. Measure urinary output: Measuring output is important once urination occurs but does not assist with initiating voiding. It is a monitoring step, not an intervention to promote urination. It should follow once the client successfully voids.
C. Assist to the bathroom: Walking to the bathroom creates a familiar and private setting, promoting comfort and relaxation. These factors help stimulate the natural urge to void. It also supports mobility and patient independence postoperatively.
D. Place a urinary catheter: Catheterization is invasive and should only be done if noninvasive methods fail. It increases the risk of infection and discomfort. Nurses should try simpler interventions first to promote spontaneous voiding.
E. Assist the client to stand: Postural positioning, such as standing, helps mimic the client’s usual urination habits. This can help engage the bladder’s normal neurological pathways. It is especially helpful in male clients to initiate urination.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. "Removing the tumor is a primary treatment for colon cancer.": Surgical removal is primary in early-stage cancer, but not when metastasis is widespread. At this point, the focus shifts from curative to palliative care.
B. "Once the tumor is removed, cell pathology can be determined.": Pathology is typically confirmed through prior biopsies. Surgery in advanced cases is not usually done for diagnostic purposes.
C. "Tumor removal will promote comfort.": In metastatic colon cancer, surgery is often palliative, aiming to relieve symptoms such as pain, obstruction, or bleeding. The goal is to enhance quality of life.
D. "This surgery will prevent further tumor growth.": With metastasis to the liver and bone, tumor growth is likely ongoing elsewhere. Surgery may reduce local tumor burden but does not prevent systemic progression.

A. "Do you eat three meals per day?" B. "Who eats meals with you?" C. "Do you snack in the evening?" D. "How do you prepare your food?"

Correct Answer is D

No explanation

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The nurse is caring for a postoperative client who reports difficulty urinating. The client does not have a urinary catheter in place. Which nursing action(s) are most appropriate at this time? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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