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 C

Explanation

Choice A rationale

Constant erythema and warmth in the legs are indicative of venous insufficiency due to stagnant blood flow. PAD typically presents with cool, pale extremities as a result of reduced arterial perfusion.

Choice B rationale

Discomfort typically worsens when legs are elevated in PAD because elevation further impairs blood flow, causing ischemic pain. Relief is more commonly achieved when the legs are in a dependent position, aiding perfusion.

Choice C rationale

Pain during exercise, termed intermittent claudication, occurs due to insufficient oxygen delivery to muscles. Rest alleviates symptoms as oxygen demand decreases. This hallmark feature distinguishes PAD from other circulatory disorders.

Choice D rationale

Peripheral pulses in PAD are generally diminished or absent, reflecting compromised arterial blood flow. Bounding pulses would suggest conditions such as aortic regurgitation or hyperdynamic states, not PAD.

A. Edema of the lower extremities. B. Pulmonary crackles auscultated. C. Ascites. D. Jugular vein distention.

Correct Answer is B

Explanation

Choice A rationale

Edema of the lower extremities suggests right-sided heart failure, not left ventricular failure. Fluid backs up into systemic circulation in right-sided failure, while left-sided failure primarily affects pulmonary circulation. Differentiating between these conditions is essential for targeted management.

Choice B rationale

Pulmonary crackles result from fluid accumulation in alveoli due to left ventricular failure, where decreased cardiac output causes blood to back up into pulmonary vasculature. Crackles indicate pulmonary congestion or edema. Prompt identification aids in early intervention. Normal respiratory assessment excludes crackles.

Choice C rationale

Ascites is more indicative of chronic right-sided heart failure or liver disease, not acute left ventricular failure. Ascites results from systemic venous congestion, which is less common in isolated left-sided heart failure. Differentiating causes helps refine diagnostic focus.

Choice D rationale

Jugular vein distention is associated with elevated central venous pressure, typical of right-sided heart failure or combined heart failure. It does not specifically characterize left ventricular failure. Accurate recognition of findings ensures precise diagnosis and management.

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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?

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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?