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

Rationale:
A. Temperature should be monitored more frequently in immunosuppressed clients to detect early signs of infection.
B. Fresh fruit can introduce bacteria or fungi, increasing infection risk in immunosuppressed clients.
C. Limiting the number of health care workers entering the room helps reduce the risk of infection by minimizing exposure to potential pathogens.
D. An indwelling catheter can increase the risk of infection and should be avoided unless absolutely necessary.

A. Prophylactic antibiotics B. Packed RBCs C. Recombinant factor VIII D. Fresh frozen plasma

Correct Answer is C

Explanation

A. Prophylactic antibiotics are not routinely given solely because of hemophilia A. They may be indicated based on the client's overall health and the procedure.
B. Packed RBCs are not typically needed for wisdom teeth extractions in clients with hemophilia A, as these procedures do not usually cause significant blood loss.
C. Recombinant factor VIII is the specific treatment for hemophilia A and is administered prior to procedures to prevent bleeding.
D. Fresh frozen plasma contains clotting factors but is not the treatment of choice for hemophilia A. Recombinant factor VIII is preferred due to its specific action and lower risk of complications.

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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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