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 B

Explanation

The PCA (patient-controlled analgesia) pump is programmed to deliver a dose of 0.5 mg of morphine every 15 minutes as needed. This setup means that only 1 dose can be administered every 15 minutes, regardless of how many times the patient presses the button.

Since 60 minutes have passed, the maximum number of doses the patient could receive is calculated as follows:

60 minutes/ 15 minutes per dose= 4 doses

Even though the patient pressed the button 10 times, the pump will only deliver a dose every 15 minutes, resulting in 4 doses.

A. Tell others that personal biases cannot be changed. B. Realize nothing can be done to change one's values and beliefs. C. Ask peers and colleagues how they practice cultural diversity. D. Objectively examine one's own bias, beliefs, values, and practices.

Correct Answer is D

Explanation

. Objectively examining one's own bias, beliefs, values, and practices is the best way for nurses to develop an awareness of their own culture and bias. It is important for nurses to recognize that they have their own set of beliefs and values that may influence their perceptions and interactions with patients from different cultural backgrounds. Through selfreflection and self-awareness, nurses can identify their own biases and work towards addressing them. This will help nurses provide culturally competent care and build trusting relationships with their patients. Choices A and B are incorrect because they imply that personal biases cannot be changed, which is not true. Choice C may provide some insight into how other nurses practice cultural diversity, but it does not address the nurse's own personal biases and cultural background.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is on a PCA pump following an abdominal surgery. The order states the client can have 0.5mg morphine every 15 minutes as needed. The client pushed the button 10 times in the past 60 minutes. How many doses did the client receive?

Correct Answer is B

Explanation

What would be the best way for nurses to develop an awareness of their own culture and bias?

Correct Answer is D

Explanation

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