A client has not voided eight hours after surgery and says to the nurse, “I don’t think I can urinate.” What should be the first action for the nurse?
Assess the client’s bladder.
Administer pain medication.
Increase the client’s fluid intake.
Inform the surgeon of the client’s status.
The Correct Answer is A
The nurse should first assess the client’s bladder for distention by palpating the lower abdomen between the symphysis pubis and the umbilicus.
This can indicate urinary retention, which is a common postoperative complication. The nurse should also measure the bladder volume using a bladder scanner if available.
Choice B. Inform the surgeon that the client’s status is wrong because the nurse should first assess the client before notifying the surgeon.
The surgeon may order interventions based on the assessment findings.
Choice C. Increasing the client’s fluid intake is wrong because increasing fluid intake may worsen bladder distention and discomfort.
The nurse should encourage fluid intake only after ensuring adequate urinary output.
Choice D. Administering pain medication is wrong because pain medication may not be indicated for urinary retention.
Pain medication may also cause urinary retention by relaxing the bladder muscles and impairing the micturition reflex.
Normal urine output is about 30 mL per hour or 240 mL in eight hours.
The nurse should monitor the client’s intake and output and report any signs of urinary retention to the surgeon.
Urinary retention can lead to infection, bladder damage, and renal impairment if not treated promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is because gelatin is a low-fat dessert that contains only 0.1 grams of fat per cup.
It is also low in calories and can be flavored with fruit juice or fresh fruits for added nutrition.
Choice A is wrong because a slice of fruit pie contains about 14 grams of fat per slice, which is high for a low-fat diet.
Fruit pies also have added sugar and refined flour that can increase the calorie intake.
Choice C is wrong because a bran muffin contains about 9 grams of fat per muffin, which is also high for a low-fat diet.
Bran muffins may have some fiber benefits, but they also have added sugar and oil that can make them less healthy.
Choice D is wrong because one plain doughnut contains about 11 grams of fat per doughnut, which is also high for a low-fat diet.
Doughnuts are deep-fried and have a lot of sugar and refined flour that can contribute to weight gain and health problems.
Some other examples of low-fat dessert choices are sorbet, fruit salad, yogurt, pudding, and angel food cake.
These desserts are lower in fat and calories than pies, muffins, and doughnuts, and can satisfy a sweet tooth without compromising the dietary instructions.
Correct Answer is B
Explanation
Ineffective protection related to chemotherapy side effects. This nursing diagnosis takes priority for a client who is receiving chemotherapy
treatment for cancer because chemotherapy can cause immunosuppression and increase the risk of infection, bleeding, and other complications.
According to the NANDA-I taxonomy, ineffective protection is defined as “decreased ability of an individual to guard the self from internal or external threats such as illness or injury” (NANDA International, 2018).
Choice A is wrong because situational low self-esteem related to job loss due to chemotherapy side effects is not a priority diagnosis for a client who is receiving chemotherapy treatment for cancer. Although chemotherapy can affect the client’s self-image and emotional well-being, it is not a life-threatening condition and can be addressed after ensuring the client’s safety and physiological needs.
Choice C is wrong because anticipatory grieving related to a cancer diagnosis is not a priority diagnosis for a client who is receiving chemotherapy treatment for cancer. Although cancer can cause emotional distress and grief for the client and their family, it is not an immediate threat to the client’s health and can be managed with psychological support and counseling.
Choice D is wrong because fatigue related to cancer treatments is not a priority diagnosis for a client who is receiving chemotherapy treatment for cancer. Although chemotherapy can cause fatigue and weakness, it is not a critical condition and can be alleviated with rest, nutrition, and energy conservation strategies.
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