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 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.

A. A client received gentamicin intermittent IV bolus over 1 hr. B. A nurse injected Demerol IM into the vastus lateralis site of adult. C. A client received a crushed bupropion XL tablet mixed with applesauce. D. A nurse used a 25-gauge / inch needle to administer a heparin injection.

Correct Answer is C

Explanation

A. Gentamicin administered over 1 hour is an appropriate method for this medication.
B. Injecting Demerol IM into the vastus lateralis is an acceptable site for adults.
C. Crushing bupropion XL (extended-release) tablets is contraindicated as it alters the drug's release mechanism, which can lead to a risk of overdose or ineffective treatment, requiring an incident report.
D. Using a 25-gauge ⅝ inch needle for heparin injection is an appropriate technique.

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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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