A nurse is caring for a client who is 1 hr postpartum and unable to urinate.
Which of the following actions should the nurse take?
Place the client's hands in warm water.
Perform a fundal massage.
Administer a benzodiazepine.
Place an ice pack on the client's perineum.
The Correct Answer is A
Choice A rationale:
Placing the client's hands in warm water is a method to stimulate urination and is appropriate for clients experiencing difficulty voiding.
Choice B rationale:
Performing a fundal massage is incorrect choice in this scenario.
Choice C rationale:
Administering a benzodiazepine is not appropriate for this situation. Benzodiazepines are a class of medications primarily used for anxiety, insomnia, and seizures. There is no indication for the use of benzodiazepines in this case, as the client's inability to urinate is likely related to a physiological issue postpartum, not anxiety or seizures.
Choice D rationale:
Placing an ice pack on the client's perineum is not the correct intervention for this situation. Ice packs on the perineum are typically used to reduce swelling and relieve pain after childbirth. However, the client's inability to urinate suggests a potential issue within the urinary system, and a fundal massage to promote uterine contractions would be more appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Amputation, although a significant medical history, is not a contraindication to becoming a living kidney donor. The presence of an amputation does not directly impact the person's ability to donate a kidney to their parent.
Choice B rationale:
Primary glaucoma, a condition affecting the eyes, is also not a contraindication to kidney donation. While eye conditions can affect overall health, they do not specifically prevent an individual from donating a kidney if they are otherwise healthy.
Choice C rationale:
Hypertension (high blood pressure) is a contraindication to kidney donation. Individuals with hypertension are at a higher risk of developing kidney disease themselves. Additionally, donating a kidney could exacerbate their condition, potentially leading to further complications. Therefore, this is the correct choice.
Choice D rationale:
Osteoarthritis, a condition affecting the joints, is not a contraindication to kidney donation. Joint problems do not directly impact kidney function or the ability to donate a kidney.
Correct Answer is D
Explanation
Explanation: Yellow patches in the mouth are an indication of oral candidiasis, also known as thrush, which is a fungal infection caused by Candida albicans. Oral candidiasis can cause symptoms such as pain, burning, redness, and difficulty swallowing in addition to yellow patches on the tongue, palate, cheeks, or throat. Hearing loss, night sweats, and
brittle nails are not manifestations of candida infection.
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