After a client voids, 150 mL of residual urine is measured. Which nursing problem should be included in this client’s plan of care?

Imbalanced nutrition.

Deficient fluid volume.

Risk for infection.

Urinary incontinence.

Answer and Explanation

The Correct Answer is C

Choice A reason: Imbalanced nutrition is unrelated to 150 mL residual urine, which indicates incomplete bladder emptying, often from detrusor dysfunction or obstruction. Nutrition affects overall health but does not cause retention. Residual urine increases infection risk due to stasis, making nutrition an irrelevant nursing problem for this urinary issue.

Choice B reason: Deficient fluid volume suggests dehydration, reducing urine output, not causing high residual volumes. Residual urine (150 mL) indicates retention from impaired bladder emptying, not fluid deficit. Hydration prevents stasis, but infection risk from retained urine is more immediate, as bacteria proliferate in stagnant urine.

Choice C reason: Residual urine of 150 mL signifies incomplete bladder emptying, often from obstruction or neurogenic bladder, leading to urinary stasis. This fosters bacterial growth, increasing urinary tract infection (UTI) risk. Including “risk for infection” addresses this pathophysiological concern, guiding interventions like catheterization to reduce infection likelihood.

Choice D reason: Urinary incontinence involves involuntary leakage, not retention, where the bladder fails to empty, as seen with 150 mL residual urine. Retention results from outflow obstruction or weak detrusor, distinct from incontinence’s loss of control, making this nursing problem inappropriate for the client’s condition.

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Correct Answer is C

Explanation

Choice A reason: Feeling emptiness reflects depression but is less urgent than access to firearms in suicidal ideation. Firearms indicate immediate risk, requiring safety planning. Emptiness needs therapy but not priority documentation, per suicide risk assessment and mental health nursing protocols.

Choice B reason: Monthly panic attacks are relevant but not the highest priority in suicidal ideation. Firearm access poses an immediate lethal risk, requiring urgent documentation. Panic attacks are secondary, per suicide risk assessment and psychiatric nursing care standards.

Choice C reason: Documenting firearm access is critical, as it indicates a means for suicide in a client with suicidal ideation. This prompts immediate safety interventions, like removing access, to prevent harm, per suicide risk assessment and patient safety protocols in psychiatric nursing.

Choice D reason: The daughter as a reason to live is protective but less urgent than firearm access, which poses immediate risk. Firearms require priority documentation to ensure safety. This is secondary, per suicide prevention and mental health assessment standards in nursing.

A. Administer an IV narcotic analgesic. B. Adjust compression device until client is comfortable. C. Turn the client to a left side-lying position. D. Assess the femoral PCI access site for a hematoma.

Correct Answer is D

Explanation

Choice A reason: Administering an IV narcotic masks pain without addressing its cause. Pain at the PCI site may indicate hematoma or arterial injury, common post-PCI due to vessel trauma and tirofiban’s antiplatelet effects. Assessing the site identifies bleeding, critical to prevent complications like hemorrhage before providing analgesia.

Choice B reason: Adjusting the compression device without assessment risks worsening a hematoma, as excessive pressure impairs flow, while insufficient pressure fails to control bleeding. Tirofiban increases bleeding risk. Assessing for hematoma ensures proper management, preventing vascular complications, making adjustment premature without confirming the pain’s cause.

Choice C reason: Turning to a left side-lying position does not address PCI site pain, potentially from hematoma or arterial injury. Post-PCI, supine positioning minimizes site stress. Assessing for hematoma, exacerbated by tirofiban’s anticoagulation, is critical to detect bleeding, preventing complications like retroperitoneal hemorrhage over positional changes.

Choice D reason: Assessing the femoral PCI site for hematoma is essential, as pain may indicate bleeding, common post-PCI with tirofiban’s platelet inhibition. Hematoma can compress vessels, causing ischemia or rupture, requiring urgent intervention like compression or surgery. This addresses the pathophysiological risk, ensuring vascular stability and patient safety.

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After a client voids, 150 mL of residual urine is measured. Which nursing problem should be included in this client’s plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is D

Explanation

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