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. A client with a leg ulcer may have limited mobility but not necessarily the highest fall risk.
B. An adolescent using crutches is at some risk but typically has better balance and coordination than older adults.
C. An older adult who is confused and has urinary frequency is at the highest risk for falls due to impaired cognitive function and frequent need to get up to use the bathroom, which increases the likelihood of falls.
D. A postoperative client with assistance is less likely to fall compared to an unassisted confused older adult.
Correct Answer is D
Explanation
A. Lactated Ringer's does not provide the necessary glucose to prevent hypoglycemia in clients receiving TPN.
B. 3% sodium chloride is hypertonic and not appropriate for preventing hypoglycemia.
C. 0.9% sodium chloride does not provide the necessary glucose.
D. Dextrose 10% in water (D10W) provides a glucose source to help prevent hypoglycemia in clients when TPN is temporarily unavailable.
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