A client in the recovery room following a procedure is unable to void, so the nurse obtains a prescription to perform a straight catheterization. After inserting the catheter, the nurse observes that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next?
Remove the catheter and palpate the client's bladder for residual distention.
Remove the catheter and replace with an indwelling catheter.
Allow the bladder to empty completely or up to 1,000 mL of urine.
Clamp the catheter for thirty minutes and then resume draining.
The Correct Answer is C
Choice A: Remove the catheter and palpate the client's bladder for residual distention. This is not the best action, as it may cause discomfort and trauma to the client. The catheter should not be removed until the bladder is fully emptied or up to 1,000 mL of urine is drained, as removing it too soon may cause urinary retention or infection.
Choice B: Remove the catheter and replace with an indwelling catheter. This is not the best action, as it may cause unnecessary exposure and trauma to the client. The catheter should not be replaced unless ordered by the healthcare provider, as replacing it may increase the risk of infection or urethral injury.
Choice C: Allow the bladder to empty completely or up to 1,000 mL of urine. This is the best action, as it can prevent bladder spasms, overdistention, or rupture. The nurse should monitor the urine output and color, and document the amount and characteristics of urine drained.
Choice D: Clamp the catheter for thirty minutes and then resume draining. This is not the best action, as it may cause pain and discomfort to the client. The catheter should not be clamped unless ordered by the healthcare provider, as clamping it may increase the risk of infection or bladder damage.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Encourage rest until the analgesic becomes effective. This is not the best intervention, as it does not address the client's preference or comfort level. The analgesic may take some time to relieve the pain, and forcing the client to lie down may increase the pressure on the pancreas and worsen the pain.
Choice B: Raise head of bed until at a 90 degree angle. This is not the best intervention, as it does not address the client's preference or comfort level. Raising the head of bed may help reduce abdominal distension and improve breathing, but it may not relieve the pain as much as leaning forward.
Choice C: Place bed in a reverse Trendelenburg position. This is not the best intervention, as it does not address the client's preference or comfort level. Placing the bed in a reverse Trendelenburg position may help shift the abdominal organs away from the pancreas and reduce inflammation, but it may not relieve the pain as much as leaning forward.
Choice D: Position bedside table so the client can lean across it. This is the best intervention, as it addresses the client's preference and comfort level. Leaning forward may help decrease the tension on the pancreas and relieve the pain. The bedside table can provide support and stability for the client while sitting up.
Correct Answer is A
Explanation
Choice B reason: Blood pressure of 122/74 mm Hg is within the normal range for a postpartum client and does not indicate an infection. However, the nurse should monitor for signs of preeclampsia or eclampsia, such as hypertension, proteinuria, headache, blurred vision, and seizures.
Choice C reason: Oral temperature of 100.2°F (37.9°C. is slightly elevated, but not necessarily indicative of an infection. A mild fever may occur within the first 24 hours after delivery due to dehydration or hormonal changes. However, if the fever persists or increases, the nurse should suspect an infection and notify the healthcare provider.
Choice D reason: White blood cell count of 19,000/mm^3 (19 x 10^9/L) is higher than the normal range, but not necessarily indicative of an infection. A leukocytosis or increased WBC count may occur as a normal response to stress or trauma during delivery. However, if the WBC count remains elevated or increases further, the nurse should suspect an infection and notify the healthcare provider.
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