The nurse is caring for a male client with a history of benign prostatic hyperplasia (BPH) who reports being unable to void any urine for the last 8 hours.
Which of the following actions should the nurse take first?

Notify a urologist to insert a metal catheter with a prostatic curve.

Prepare the client to have a cystostomy performed.

Insert an indwelling urethral catheter.

Notify the health care provider to discuss surgical options with the client.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Metal catheters with prostatic curves are used in challenging cases of urinary retention caused by BPH. However, these catheters are not the first-line intervention due to their specialized nature and the risk of injury. Less invasive measures should be tried first.

Choice B rationale

Cystostomy, a surgical procedure that creates a suprapubic urinary drainage site, is reserved for severe cases of urinary retention where catheterization fails. It is not the initial step due to its invasive nature and requirement for surgical expertise.

Choice C rationale

Inserting an indwelling urethral catheter is the first-line action for managing acute urinary retention associated with BPH. It provides immediate bladder decompression, relieves discomfort, and reduces risks of complications like hydronephrosis or bladder rupture.

Choice D rationale

Discussing surgical options addresses the long-term management of BPH but does not resolve acute urinary retention. Interventions like catheterization should first alleviate symptoms before evaluating the need for definitive surgical treatment. .

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Correct Answer is D

Explanation

Choice A rationale

Hypotension is not a typical sign of fluid overload. Fluid overload often presents with hypertension due to increased circulatory volume. Monitoring blood pressure is essential, but hypotension does not reliably indicate fluid overload. This option does not align with scientific understanding of fluid overload symptoms.

Choice B rationale

Distention above the pubis area suggests urinary retention or bladder distension rather than fluid overload. While important to assess, it does not directly indicate fluid overload. This symptom is more related to mechanical issues than systemic fluid imbalance and volume overload.

Choice C rationale

Hypernatremia is not a sign of fluid overload. Fluid overload typically results in dilutional hyponatremia, where excessive fluids lower sodium levels. Monitoring sodium levels is useful, but hypernatremia would suggest dehydration or other conditions, not excess fluid volume. This choice is inconsistent with scientific knowledge.

Choice D rationale

Maintaining strict intake and output records is a fundamental approach to monitoring fluid balance. Accurate measurements of fluid intake and output help detect fluid overload early. This method directly correlates with assessing excess fluid volume in clinical practice. It is a reliable, evidence-based intervention for monitoring fluid status. .

A. "I am going to notify the healthcare provider because you should not have trouble breathing with left-sided heart failure.”. B. "The right side of your heart fails first and causes a back-up of blood in the left side of the heart and then the lungs.”. C. "When the left side of your heart does not pump enough blood out, it gets backed up in your lungs and causes shortness of breath.”. D. "Typically, clients with left-sided heart failure have difficulty breathing with exertion, but not when resting.”.

Correct Answer is C

Explanation

Choice A rationale

Trouble breathing is a hallmark symptom of left-sided heart failure. Suggesting that it should not occur would be inaccurate. The failure of the left ventricle leads to blood accumulation in the pulmonary vessels, creating pulmonary congestion and shortness of breath. Prompt provider notification may be necessary but does not address the underlying pathophysiology. Pulmonary symptoms are expected in this type of heart failure.

Choice B rationale

While left-sided heart failure can eventually lead to right-sided heart failure, the initial problem is with left ventricular dysfunction. This causes reduced forward blood flow and pulmonary congestion due to backflow of blood into the lungs. Right-sided heart failure is not the primary event leading to pulmonary symptoms in left-sided heart failure.

Choice C rationale

The left ventricle's inability to pump effectively results in blood backing up into the pulmonary circulation, causing pulmonary congestion and symptoms like shortness of breath. This is consistent with the hemodynamics of left-sided heart failure. Pulmonary capillary pressure increases, leading to fluid leakage and impaired gas exchange, explaining the client's breathing difficulty.

Choice D rationale

Although difficulty breathing with exertion (dyspnea on exertion) is common, resting symptoms, including orthopnea and paroxysmal nocturnal dyspnea, can also occur in left-sided heart failure due to fluid redistribution. Limiting symptoms to exertion inaccurately portrays the clinical presentation and disregards other significant pulmonary signs.

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The nurse is caring for a male client with a history of benign prostatic hyperplasia (BPH) who reports being unable to void any urine for the last 8 hours.Which of the following actions should the nurse take first?

Nursing Test Bank

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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The nurse is caring for a male client with a history of benign prostatic hyperplasia (BPH) who reports being unable to void any urine for the last 8 hours.
Which of the following actions should the nurse take first?