What would the nurse anticipate to be used to treat this imbalance?
Your patient had a Foley catheter removed four hours ago, but reports the inability to void with a subjective sensation of needing to urinate. Which action should the nurse perform FIRST?
Select one:
initiate hourly intake and output.
gently palpate over the symphysis pubis for bladder fullness.
put the patient on the toilet and turn on the water.
notify the RN or the healthcare provider.
The Correct Answer is B
A. While tracking intake and output is important, it does not directly address the patient’s current complaint or help identify urinary retention.
B.The first action is to assess the bladder for distention by palpating above the symphysis pubis. This helps determine if the bladder is full and not emptying, which may indicate urinary retention.
C. Encouraging natural voiding techniques (like running water) is appropriate, but only after assessment confirms the bladder is not overly distended.
D. Notifying the provider is important if interventions fail, but the nurse should first assess before escalating the situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While tracking intake and output is important, it does not directly address the patient’s current complaint or help identify urinary retention.
B.The first action is to assess the bladder for distention by palpating above the symphysis pubis. This helps determine if the bladder is full and not emptying, which may indicate urinary retention.
C. Encouraging natural voiding techniques (like running water) is appropriate, but only after assessment confirms the bladder is not overly distended.
D. Notifying the provider is important if interventions fail, but the nurse should first assess before escalating the situation.
Correct Answer is A
Explanation
b.i.d. means twice a day
7 days × 2 doses per day = 14 doses
If each tablet is 80 mg (as ordered), then one tablet is needed per dose
Therefore, the nurse will need 14 tablets to cover the full 7-day period.
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