A nurse is caring for a client who is postpartum and reports difficulty voiding. Which of the following findings should indicate to the nurse that the client's ability to eliminate urine from the bladder is restored?

Fundus 2 fingerbreadths above the umbilicus

Uterine atony

Fundus firm and to the right of the abdominal midline

Two voids of 150 mL each over the past 2 hr

Answer and Explanation

The Correct Answer is D

A. Fundus 2 fingerbreadths above the umbilicus: This finding relates to uterine involution rather than urinary elimination. While important for postpartum assessment, it does not indicate restored bladder function.

B. Uterine atony: Uterine atony is a complication that increases the risk of postpartum hemorrhage. It does not provide information about the client’s ability to void and requires separate monitoring and intervention.

C. Fundus firm and to the right of the abdominal midline: A firm but displaced fundus may indicate a full bladder, which can interfere with urination. This finding suggests bladder distention rather than restored urinary elimination.

D. Two voids of 150 mL each over the past 2 hr: Adequate urine output in regular intervals indicates that the bladder is emptying effectively. Measuring volume and frequency confirms the client’s ability to eliminate urine has been restored postpartum.

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Correct Answer is D

Explanation

A. Start another IV line in another extremity: Establishing a new IV line is necessary to continue therapy, but it is not the first action. Immediate steps must focus on preventing further tissue damage from the infiltrated vesicant.

B. Apply a warm, moist compress: Warm or cold compresses may be applied depending on the type of vesicant and institutional protocol, but this is a secondary intervention after stopping the infusion and protecting the tissue.

C. Disconnect IV tubing and aspirate medication from the IV catheter: Aspirating the remaining medication may help reduce tissue exposure, but it is performed after the infusion is stopped to prevent further infiltration.

D. Stop the infusion: Stopping the infusion immediately is the first and most critical action to prevent further tissue damage. Halting the delivery of the vesicant stops the source of injury and allows subsequent interventions to minimize local tissue necrosis.

A. Allow extra time for the client to perform tasks. B. Touch the client gently to announce presence. C. Keep objects in the client's room in the same place. D. Approach the client from the side. E. Ensure there is high-wattage lighting in the client's room.

Correct Answer is ["A","C"]

Explanation

A. Allow extra time for the client to perform tasks: Clients with vision loss may require additional time to navigate their environment and complete activities safely. Providing extra time reduces stress, supports independence, and promotes a sense of autonomy while performing daily tasks.

B. Touch the client gently to announce presence: The nurse should announce presence verbally first. Touching without warning may startle the client.

C. Keep objects in the client's room in the same place: Maintaining a consistent arrangement of personal items prevents confusion and reduces the risk of falls or accidents. Predictable placement allows the client to perform tasks safely and maintain independence.

D. Approach the client from the side: Approaching from the side is not recommended because it may startle the client. Best practice is to approach from the front while using verbal cues to announce your presence and provide orientation.

E. Ensure there is high-wattage lighting in the client's room: High-intensity lighting may cause glare and discomfort for clients with vision loss, especially those with conditions like macular degeneration. Adequate but non-glare lighting is preferable to support safe mobility.

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A nurse is caring for a client who is postpartum and reports difficulty voiding. Which of the following findings should indicate to the nurse that the client's ability to eliminate urine from the bladder is restored?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving a continuous intravenous infusion containing a vesicant that has become infiltrated. Which of the following actions should the nurse take first in treating this condition?

Correct Answer is D

Explanation

A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","C"]

Explanation

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