A client who is on complete bedrest frequently calls the nurse for the bedpan to urinate.
Which action should the nurse take to evaluate the client for urinary retention?
Review the chart for number of voids over the last 24 hours.
Evaluate the client for urinary incontinence.
Scan the client's bladder after voiding.
Palpate the suprapubic region for distention.
The Correct Answer is C
This will help determine if there is any residual urine left in the bladder after voiding.
Choice A is not the answer because reviewing the chart for the number of voids over the last 24 hours is important but not sufficient to evaluate for urinary retention.
Choice B is not the answer because evaluating for urinary incontinence is important but not sufficient to evaluate for urinary retention.
Choice D is not the answer because while palpating the suprapubic region for distention can provide some information, scanning the bladder after voiding is a more accurate way to evaluate for urinary retention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration, the head of the bed should be elevated 45 to 90 degrees to prevent aspiration1.
Therefore, if the UAP raises the head of the bed to only 80 degrees, it indicates the need for additional teaching.
Choice A is not correct because placing food on the unaffected side of the mouth is an appropriate action when feeding a client with a CVA.
Choice C is not correct because positioning the head with the chin tilted slightly downward can help prevent aspiration.
Choice D is not correct because allowing 30 minutes of rest before feeding can help improve digestion and reduce the risk of aspiration.
Correct Answer is D
Explanation
Prior to performing digital removal of a fecal impaction, it is important for the nurse to assess the client’s vital signs.
This includes checking the client’s blood pressure, pulse rate, respiratory rate, and temperature.
These measurements can provide important information about the client’s overall health status and can help the nurse determine if it is safe to proceed with the procedure.
Choice A is not correct because abdominal girth is not the most important assessment for the nurse to perform prior to performing digital removal of a fecal impaction.
Choice B is not correct because breath sounds are not the most important assessment for the nurse to perform prior to performing digital removal of a fecal impaction.
Choice C is not correct because bowel sounds are not the most important assessment for the nurse to perform prior to performing digital removal of a fecal impaction.
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