A nurse is caring for a client who has not voided for 8 hr following the removal of an indwelling urinary catheter. Which of the following actions should be the nurse take first?
Provide assistance to bathroom.
Increase fluids.
Perform a bladder scan.
Insert a straight catheter.
The Correct Answer is C
A. Providing assistance to the bathroom is appropriate but should follow assessment and intervention for urinary retention.
B. Increasing fluids may be beneficial but does not address the immediate need to assess for urinary retention.
C. Performing a bladder scan is the first action to assess if the client has urine in the bladder and needs further intervention.
D. Inserting a straight catheter is a potential intervention but should be based on assessment findings from the bladder scan.
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Related Questions
Correct Answer is C
Explanation
A. Pediculicide lotions are used to treat lice, not ticks. They are not effective or appropriate for tick removal.
B. Twisting a tick during removal can cause the mouthparts to break off and remain embedded in the skin, increasing the risk of infection.
C. Grasping the tick as close to the skin as possible with fine-tipped tweezers allows for complete removal without squeezing the tick's body.
D. Using a hot ember or match tip can cause the tick to regurgitate into the skin, increasing the risk of disease transmission.
Correct Answer is A
Explanation
A. Daily antihistamines can help control itching associated with atopic dermatitis.
B. Solid carbon dioxide is not used to treat atopic dermatitis.
C. Mouth cleansing is not relevant for atopic dermatitis, which primarily affects the skin.
D. Antibiotics are not typically used for atopic dermatitis unless there is a secondary bacterial infection.
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