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.

Answer and Explanation

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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Free Nursing Study Resources

Correct Answer is ["100"]

Explanation

To calculate the flow rate for an IV fluid bolus, you can use the formula: (Volume in mL * Drop factor) / Time in minutes. For a 200 mL dextrose 5% in water to be administered over 30 minutes with a drop factor of 15 gtt/mL, the calculation would be (200 * 15) / 30, which equals 100 gtt/min.

A. Skin color B. Temperature C. Fluid intake D. Hemoglobin level

Correct Answer is B

Explanation

A. Skin color is not the most critical parameter before a blood transfusion.
B. Temperature is important to monitor for baseline and the temperature should be monitored during infusion since an increase in temperature can indicate a transfusion reaction.
C. Fluid intake is relevant to assess overall hydration status but not the most critical before the transfusion.
D. Hemoglobin level is crucial to determine but it is not the most important data to obtain immediately before the infusion, as it does not change rapidly during the transfusion and does not indicate an ongoing reaction.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["100"]

Explanation

A nurse is assessing a client before administering a unit of packed RBCs. The nurse should identify which of the following data as most important to obtain prior to the infusion?

Correct Answer is B

Explanation

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