A client had his Foley catheter removed six hours ago and has just voided for the first time. The nurse performs a bladder scan to check for any post-void residual. The results of the post-void residual (PVR) from the bladder scan are 400mL of urine. What should the nurse do next?

Recognize this as a normal PVR and document the amount in the patient's chart.

Recognize this as an abnormal PVR, call the physician, and recommend an external catheter be applied.

Recognize this as an abnormal PVR, call the physician, and obtain an order for an in-and-out catheterization.

Recognize this as an abnormal PVR and try to have the client void again in a few hours.

Answer and Explanation

The Correct Answer is C

A. This option is incorrect because a PVR of 400 mL is significantly higher than normal. Documenting without further intervention could lead to complications if the high residual volume persists.

B. While an external catheter may be beneficial for managing incontinence or monitoring urine output, it does not address the underlying issue of urinary retention. An external catheter would not relieve the retained urine in the bladder.

C. A post-void residual (PVR) of 400 mL is abnormally high, indicating that the bladder is not emptying effectively, which can lead to discomfort, urinary tract infection (UTI), and potential kidney issues if left untreated. An in-and-out catheterization allows for temporary relief by emptying the bladder and can also help prevent bladder distention. Contacting the physician to report the findings and obtain an order is appropriate to manage this condition safely.

D. Encouraging the client to attempt voiding again without intervention may not be effective in reducing the high PVR. This delay could increase the risk of bladder distention and discomfort.

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Correct Answer is A

Explanation

The correct answer is choice A, moisture in air passages. Crackles, also known as rales, are abnormal lung sounds that can indicate a buildup of fluid in the lungs. The moisture in the air passages causes the sound of air moving through fluid or mucus, leading to a crackling sound. Crackles can be heard in conditions such as pneumonia, heart failure, and pulmonary fibrosis.

A. Listen with a stethoscope at the second intercostal space left sternum B. Listen with the stethoscope at the fifth intercostal space at the sternum C. C. Listen with the stethoscope at the fifth intercostal space left mid clavicular line D. Listen with a stethoscope at the neck to the right of the coracoid process.

Correct Answer is C

Explanation

The correct answer is choice C: Listen with the stethoscope at the fifth intercostal space left mid clavicular line. This is the correct location to auscultate the apical pulse or apical heart rate. The apical pulse is the sound of the heart beating heard through a stethoscope placed over the apex of the heart, which is located at the fifth intercostal space at the left mid-clavicular line. The second intercostal space at the left sternum is the location to auscultate the aortic valve, while the fifth intercostal space at the sternum is the location to auscultate the tricuspid valve. The neck to the right of the coracoid process is not a location to auscultate the apical pulse.

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A client had his Foley catheter removed six hours ago and has just voided for the first time. The nurse performs a bladder scan to check for any post-void residual. The results of the post-void residual (PVR) from the bladder scan are 400mL of urine. What should the nurse do next?

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Naxlex Comprehensive Predictor Exams

While assessing breath sounds, a nurse hears crackles. What causes these lung sounds?

Correct Answer is A

Explanation

A nurse can most accurately assess a client's apical heart rate by which of the following methods?

Correct Answer is C

Explanation

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