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
Simulation activities provide a safe and controlled environment for young adult clients to practice problem-solving strategies and learn from their experiences .
Choice A is not the answer because providing a physical demonstration may be helpful in teaching a skill, but it does not actively engage the clients in problem-solving .
Choice C is not the answer because incorporating verbal analogies can help clients understand concepts, but it does not actively engage them in problem-solving .
Choice D is not the answer because offering positive reinforcement can encourage and motivate clients, but it does not actively engage them in problem-solving .
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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