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
To exercise the hinge joints, the nurse should instruct the client to bend the arm by flexing the ulna to the humerus.
Hinge joints allow for movement in one direction, like a door hinge. The elbow joint is an example of a hinge joint.
Choice A is not the answer because tapping the feet forwards and backwards exercises the ankle joint, which is not a hinge joint.
Choice C is not the answer because turning the head to the right and left exercises the pivot joint in the neck, which is not a hinge joint.
Choice D is not the answer because extending the arm at the side and rotating in circles exercises the ball-and-socket joint in the shoulder, which is not a hinge joint.
Correct Answer is B
Explanation
If a nurse observes that a client is using accessory muscles, it indicates an obstruction of the airways, which reduces oxygen saturation.
Accessory muscles help in the act of forced expiration to wash out carbon dioxide and improve oxygen saturation 1.
Therefore, the nurse should obtain the respiratory rate first.
Choice A is not the answer because determining pulse pressure will not provide any significant indication of respiratory distress 1.
Choice C is not the answer because temperature does not provide any significant data about the use of accessory muscles in respiration 1.
Choice D is not the answer because pulse rate does not provide any significant data about the use of accessory muscles in respiration 1.
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