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 A

Explanation

Rationale:
A. Negligence involves failing to provide care that a reasonably prudent nurse would provide, such as leaving a shift early without proper handoff or notification, which could compromise patient safety.
B. Battery involves unlawful touching of a patient without consent, which is not applicable in this situation.
C. Slander involves making false spoken statements that harm a person's reputation, which is not applicable in this situation.
D. Libel involves making false written statements that harm a person's reputation, which is not applicable in this situation.

A. Measure abdominal girth twice weekly. B. Monitor for the presence of WBCs in the urine. C. Apply pressure to needlestick sites for 10 min. D. Assess core temperatures using a rectal thermometer.

Correct Answer is C

Explanation

Rationale:
A. Measuring abdominal girth is not directly related to thrombocytopenia management.
B. Monitoring for WBCs in the urine is not related to thrombocytopenia.
C. Applying pressure to needlestick sites for 10 minutes helps prevent bleeding, which is crucial for clients with thrombocytopenia.
D. Using a rectal thermometer can increase the risk of bleeding and should be avoided in clients with thrombocytopenia.

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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

A nurse plans to leave her scheduled shift an hour early without permission or notification of the charge nurse. The clients in the nurse's assignment are stable. Which of the following legal torts applies to this situation?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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