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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
To administer the correct dose of penicillin G benzathine, which is 1.2 million units, and given that the available concentration is 600,000 units per mL, the nurse should calculate the volume to administer based on these values. By dividing the prescribed dose by the concentration available, the nurse can determine the volume needed for injection. In this case, 1.2 million units divided by 600,000 units per mL results in 2 mL.
Correct Answer is A
Explanation
Rationale:
A. Furosemide is a loop diuretic that helps to lower potassium levels, making it appropriate for a client with hyperkalemia (potassium level of 5.3 mEq/L).
B. Potassium iodide would further increase potassium levels, which is contraindicated in this situation.
C. Digoxin does not directly affect potassium levels and could be dangerous in the context of hyperkalemia.
D. Lisinopril is an ACE inhibitor that can increase potassium levels, which would not be appropriate for this client.
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