A nurse is using a bladder scanner to measure the bladder volume of a patient who is experiencing frequent urination.
In what position should the nurse place the patient?
Sims’ position
Dorsal recumbent position
Supine position
High Fowler’s position
The Correct Answer is C
Rationale for Choice A:
Sims' position is a side-lying position with the lower arm and leg flexed and the upper arm and leg extended. It is not ideal for bladder scanning because it can displace the bladder and potentially lead to inaccurate readings. While it can be used for other purposes, such as inserting rectal suppositories or performing vaginal exams, it's not the optimal choice for bladder scanning.
Rationale for Choice B:
Dorsal recumbent position is a supine position with the knees bent and feet flat on the bed. While it provides some exposure of the bladder, it may not fully visualize the entire bladder due to potential compression from the abdominal contents. This can also result in inaccurate readings.
Rationale for Choice D:
High Fowler's position is a semi-sitting position with the head of the bed elevated at a 45- to 60-degree angle. This position is not suitable for bladder scanning because it can cause the bladder to shift upward and out of the optimal scanning range. It's typically used for respiratory comfort and procedures involving the head and upper body.
Rationale for Choice C:
Supine position is the best position for bladder scanning because it allows for the most accurate visualization of the bladder. In this position, the patient lies flat on their back with their legs extended. This position allows the bladder to rest naturally in the pelvic cavity, ensuring optimal positioning for the bladder scanner to capture a clear image and provide an accurate measurement of bladder volume. It also promotes patient comfort and relaxation during the procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Anxiety is a valid concern for any client undergoing surgery, but it is not the priority nursing diagnosis in this case. The client's risk for infection is more pressing due to the following factors:
Large surgical wound: Wounds provide a potential entry point for pathogens.
Obesity: Excess adipose tissue can impair wound healing and increase the risk of infection.
Corticosteroid medications: These medications suppress the immune system, making it more difficult for the body to fight off infection.
Choice B rationale:
Self-care Deficit may be a concern if the client has difficulty caring for the surgical wound or maintaining hygiene due to obesity. However, it is not the priority diagnosis in this case. The focus should be on preventing infection, which would also help to address any self-care deficits.
Choice D rationale:
Risk for Imbalanced Nutrition is a relevant diagnosis for a client who has had colon surgery, as they may experience changes in appetite, digestion, or absorption of nutrients. However, it is not the priority diagnosis in this scenario. Preventing infection is crucial to ensure proper wound healing and overall recovery.
Choice C rationale:
Risk for Infection is the priority nursing diagnosis for this client due to the following risk factors: Large surgical wound: The wound provides a potential entry point for bacteria and other pathogens.
Obesity: Excess adipose tissue can impair wound healing by reducing blood flow to the area and increasing the risk of wound dehiscence (separation of wound edges). This can create a favorable environment for bacterial growth.
Corticosteroid medications: These medications suppress the immune system, making it more difficult for the body to fight off infection.
Nursing interventions to address Risk for Infection:
Assess the wound regularly for signs of infection, such as redness, swelling, warmth, pain, or purulent drainage. Implement strict aseptic technique when caring for the wound.
Teach the client about proper wound care and hygiene practices.
Monitor the client for signs of systemic infection, such as fever, chills, or malaise. Administer antibiotics as prescribed.
Encourage adequate nutrition and hydration to support wound healing.
Collaborate with the healthcare team to manage the client's risk factors for infection.
Correct Answer is ["B","C","E"]
Explanation
A. Pale, yellow urine: While pale yellow urine can be a symptom of a UTI, it is not specific enough and can be caused by other factors like dehydration or certain medications. Therefore, it is not a reliable indicator of a UTI in this case.
B. Cloudy urine: Cloudy urine is a more specific symptom of a UTI, as it can indicate the presence of white blood cells or bacteria in the urine. This finding, along with other symptoms, suggests a possible UTI.
C. Suprapubic pain: Suprapubic pain, which is pain felt above the pubic bone in the lower abdomen, is a common symptom of bladder infections, including UTIs. This finding is highly suggestive of a UTI in this client.
D. Temperature of 38.2 C (100.7 F): Although fever can be a symptom of a UTI, it is not always present and can be caused by other infections or conditions. Therefore, a single elevated temperature, without other supporting symptoms, is not conclusive for a UTI diagnosis.
E. Constant urge to urinate (dysuria): Dysuria, or a frequent and urgent need to urinate, is another common symptom of UTIs. This finding, along with cloudy urine and suprapubic pain, further strengthens the suspicion of a UTI in this client.
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