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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Correct Answer is B

Explanation

A. Taking salt tablets can lead to electrolyte imbalances and is not recommended for managing heat-related issues.
B. Drinking extra fluids helps prevent dehydration and is an effective measure to prevent heat-related illness.
C. Moving to a cool environment when feeling confused is important but is a reactive measure rather than preventive teaching.
D. Taking acetaminophen for feeling too warm does not address the underlying issue of heat-related illness and is not appropriate discharge teaching for this situation.

A. Label the feeding bag with the date and time of the start of the feeding B. Hang the feeding bag 30 cm (12 in) above the client. C. Aspirate the client's stomach contents. D. Warm the feeding to room temperature.

Correct Answer is C

Explanation

A. Labeling the feeding bag is important for ensuring the safety and monitoring of feeding times, but it is not the first action.
B. Hanging the feeding bag at the correct height ensures proper flow of the feeding but is not the first action.
C. Aspirating the client's stomach contents is the first action to check for residuals and ensure the placement of the NG tube is correct, preventing aspiration.
D. Warming the feeding to room temperature is important for client comfort but is not the first action.

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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

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Correct Answer is C

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