A nurse is caring for a client who has not voided since giving birth vaginally 10 hours ago. Which of the following actions should the nurse take?
Palpate the client's bladder in 1 hour.
Place the client's hands in a bowl of cold water.
Have the client listen to running water while on the toilet.
Perform effleurage over the client's lower abdomen.
The Correct Answer is C
Rationale:
A. Palpate the client's bladder in 1 hour: Waiting another hour to assess the bladder delays intervention. At 10 hours postpartum with no void, immediate action is needed to stimulate voiding or assess for urinary retention.
B. Place the client's hands in a bowl of cold water: This technique is more commonly used in children and is less effective in stimulating voiding in postpartum adults. It is not a first-line strategy in this context.
C. Have the client listen to running water while on the toilet: This is a noninvasive and effective method to stimulate the urge to void by triggering the micturition reflex. It can help relax pelvic muscles and encourage urination postpartum.
D. Perform effleurage over the client's lower abdomen: Effleurage is a light massage technique used primarily for labor pain management. It is not a recognized or effective method to promote urination in postpartum care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. A client must create a do-not-resuscitate order when completing advance directives: A DNR is a separate medical order and is not required when completing advance directives. Clients may choose to include resuscitation preferences in their directive but are not obligated to.
B. Advance directives cannot be changed once implemented: Advance directives are flexible documents that can be revised or revoked by the client at any time, as long as the client is mentally competent. This allows clients to adjust their wishes as circumstances or preferences change.
C. Assigning a health care surrogate requires legal consultation: While laws vary by state, in most cases, a legal consultation is not required. Clients can designate a surrogate by completing a form that is often available at healthcare facilities or through state-provided templates.
D. A health care surrogate makes health care decisions when the client is no longer able: A surrogate, also known as a durable power of attorney for health care, steps in only when the client loses decision-making capacity. This ensures that the client’s preferences are respected when they cannot communicate them.
Correct Answer is B
Explanation
Rationale:
A. Troponin level: Troponin is a cardiac biomarker used to detect myocardial injury or infarction. It is not an indicator of nutritional status and does not reflect protein levels or nutrient balance.
B. Serum albumin: Albumin is a plasma protein synthesized in the liver and commonly used as a marker of long-term nutritional status. Low levels may suggest protein-energy malnutrition or chronic illness affecting nutrient absorption or intake.
C. Erythrocyte sedimentation rate: ESR is a nonspecific marker of inflammation or infection. While chronic disease can indirectly affect nutrition, ESR does not directly assess nutrient levels or dietary sufficiency.
D. Serum sodium: Sodium levels reflect fluid balance and electrolyte status but are not indicators of nutritional status. They may be influenced by hydration, renal function, or hormonal imbalances, not by dietary protein intake.
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