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 D

Explanation

A. Administering lorazepam should not be the first action for managing agitation in a client with dementia as it can increase the risk of falls and other complications.
B. Using physical restraints such as raising side rails is not recommended as a first-line intervention and can increase agitation and risks.
C. Applying a vest restraint should be avoided as it restricts the client's movement and can increase agitation and risks.
D. Placing a seat alarm in the client's chair is an appropriate initial intervention to monitor the client's movements and ensure safety while allowing some freedom of movement.

A. The client is coughing only. B. The client is not making any sounds. C. The client is able to whisper. D. The client has a high-pitched inspiratory stridor.

Correct Answer is B

Explanation

A. A client who is coughing only is still able to clear the airway by themselves.
B. Inability to make any sounds indicates a complete airway obstruction, requiring the Heimlich maneuver.
C. A client who can whisper has a partial airway obstruction and should be encouraged to continue coughing.
D. A high-pitched inspiratory stridor indicates a partial obstruction, not requiring the Heimlich maneuver but close monitoring.

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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 D

Explanation

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Correct Answer is B

Explanation

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