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

A. Placing food on the unaffected side of the mouth is appropriate for a client who has had a CVA and may have unilateral weakness. This technique helps the client chew and swallow effectively, reducing the risk of aspiration.

B. Raising the head of the bed to 80 degrees is too high and can increase the risk of choking or aspiration by making it harder for the client to control the food bolus during swallowing. A more appropriate position is raising the head of the bed to 45–60 degrees, which facilitates safe swallowing while maintaining comfort. This action requires additional teaching.

C. Positioning the head with the chin tilted slightly downward, known as the chin-tuck position, is a recommended strategy to prevent aspiration. This position helps close the airway during swallowing, reducing the risk of food or liquid entering the trachea.

D. Allowing 30 minutes of rest before feeding is appropriate because it ensures the client is not fatigued, which can compromise swallowing ability and increase the risk of aspiration.

A. On the dorsal surfaces. B. Between the toes. C. Over the heels. D. Around the ankles.

Correct Answer is B

Explanation

While drying the client’s feet, the nurse should emphasize the need to thoroughly dry between the toes.

Moisture between the toes can create a breeding ground for bacteria and fungi, which can lead to infections such as athlete’s foot 1.

Choice A is not the answer because drying on the dorsal surfaces of the feet is not as important as drying between the toes 1.

Choice C is not the answer because drying over the heels is not as important as drying between the toes 1.

Choice D is not the answer because drying around the ankles is not as important as drying between the toes 1.

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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

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Correct Answer is B

Explanation

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Correct Answer is B

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?