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.

Answer and Explanation

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.

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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.

A. "Tell me about the visit with your significant other.". B. "I can see that you are feeling lonely.". C. "Would you like to talk for a while?". D. "What did you enjoy about your visit tonight?".

Correct Answer is C

Explanation

This response shows that the nurse is willing to listen and provide support to the client.

It also allows the client to decide if they want to talk and share their feelings.

Choice A is not correct because it is not the most therapeutic response.

While it does encourage the client to talk about their visit with their significant other, it does not show that the nurse is willing to listen and provide support.

Choice B is not correct because it is not the most therapeutic response.

While it does acknowledge that the client may be feeling lonely, it does not show that the nurse is willing to listen and provide support.

Choice D is not correct because it is not the most therapeutic response.

While it does encourage the client to talk about their visit, it does not show that the nurse is willing to listen and provide support.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes that a client is using accessory muscles. Which vital sign should the nurse obtain first?

Correct Answer is B

Explanation

Which response by the nurse is most therapeutic?

Correct Answer is C

Explanation

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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?