A nurse is caring for a client who is 6 hr postoperative following abdominal surgery and is having difficulty voiding. Which of the following actions should the nurse take?
Allow the client to hear running water while attempting to void.
Provide the client a bedpan while lying supine.
Encourage fluid intake up to 1,000 mL daily.
Insert an indwelling urinary catheter and connect it to gravity drainage.
The Correct Answer is A
A. At 6 hours postoperative, difficulty voiding is common due to anesthesia effects and pain. The nurse should begin with noninvasive measures to stimulate urination. Hearing running water can help trigger the micturition reflex and promote voiding safely.
B. Lying supine may make it more difficult for the client to void. Sitting upright or ambulating to the bathroom may be more effective.
C. This is inadequate fluid intake; normal intake is usually 2,000–3,000 mL/day unless restricted. Furthermore, this does not directly address the immediate difficulty voiding.
D. Catheterization should be considered only after other interventions to promote voiding have been attempted and failed, as it carries the risk of infection and discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
A. Hypocalcemia can lead to paresthesia, including tingling sensations around the lips.
B. Abdominal distention is not typically associated with hypocalcemia.
C. Hypocalcemia can result in a positive Trousseau's sign, where carpal spasm is induced by inflating a blood pressure cuff above the systolic pressure for a few minutes.
D. Chvostek's sign is typically positive in hypocalcemia, not negative.
E. Hypocalcemia can cause muscle cramps due to increased neuromuscular excitability.
Correct Answer is C
Explanation
A. This response is associated with cranial nerve II, the optic nerve.
B. Tongue position is associated with cranial nerve XII, the hypoglossal nerve.
C. A symmetrical smile is indicative of cranial nerve VII, the facial nerve.
D. This action is associated with cranial nerve XI, the accessory nerve.
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