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 ["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.

A. Beneficence B. Autonomy C. Nonmaleficence D. Justice

Correct Answer is B

Explanation

A. Beneficence: Beneficence refers to the ethical principle of promoting good and acting in the best interest of the client. While this guides nursing actions to provide beneficial care, it does not directly involve respecting a client’s decision to refuse treatment.

B. Autonomy: Autonomy is the ethical principle that recognizes the client’s right to make independent decisions about their own healthcare. Respecting the client’s decision to refuse treatment honors their personal values, beliefs, and right to self-determination, even if the nurse disagrees with the choice.

C. Nonmaleficence: Nonmaleficence involves the obligation to avoid causing harm to the client. While important in all nursing actions, it focuses on preventing harm rather than specifically supporting a client’s right to make healthcare decisions.

D. Justice: Justice refers to fairness in the distribution of healthcare resources and treatment. It ensures equitable care for all clients but is not directly related to respecting an individual client’s choice to accept or refuse treatment.

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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 has vision loss. Which of the following actions should the nurse take? (Select all that apply.)

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

Explanation

A nurse is caring for a client who has made the decision to refuse treatment. Which of the following ethical principles is demonstrated when the nurse respects the client's decision?

Correct Answer is B

Explanation

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