A client has just voided 50 mL, yet reports that his bladder still feels full. The nurse's next actions should include which of the following? Select all that apply
a. Palpating the bladder height
b. Obtaining a clean-catch urine specimen
c. Performing a bladder scan
d. Asking the patient about his recent voiding history
e. Inserting a straight catheter to measure residual urine
A, C, D
The nurse should palpate the bladder for distention to validate the client's statement. A bladder scan will yield a more accurate measurement of the postvoid residual urine, so it would be appropriate at this time. A detailed history of the client's recent voiding patterns will assist the nurse in determining the appropriate nursing diagnosis and developing a plan of care. A clean-catch urine specimen may be necessary if further assessment shows the potential of a urinary tract infection, but is not indicated at this time. Inserting a straight catheter to measure residual urine is an invasive procedure with the risk of introducing microorganisms into the bladder. It is usually unnecessary if the nurse has access to a portable bladder scanner.
You might also like to view...
The Joint Commission standards and goals shape organization practice and documentation, thereby affecting information system documentation design. The Joint Commission assesses organizations for compliance with set standards
Which of the following statements are considered standards? Select all that apply. 1. Measures to protect information confidentiality, security, and integrity 2. Uniform definitions and methods for data capture as a means to facilitate data comparison within and among health care institutions 3. Education on the principles of information management and training for system use. This may include education about the transformation of data into information for subsequent use in decision support and statistical analysis. 4. Accurate, timely transmission of information 5. Integration of clinical systems (i.e., pharmacy, nursing, laboratory, and radiology systems) and nonclinical systems for ready availability of information
A woman with a multiple gestation of triplets loses two of her babies following delivery. The nurse anticipates that the woman will
a. probably not experience a profound grief response to the loss b. be unable to care for the surviving infants c. have the attachment process disrupted due to grief d. have intense feelings of anger and loss
A nurse checks the continuous IV infusion for the intraspinal analgesia . The IV setup should be changed if:
a. tubing with a Y-port is attached. b. an infusion pump is attached. c. the tubing connections are all taped. d. a diluted, preservative-free medication is used.
Which statement made by a client who smokes marijuana is not true?
1. "Marijuana makes me hungry." 2. "Marijuana does not increase the risk for lung cancer." 3. "Marijuana makes me paranoid." 4. "Marijuana makes me thirsty."