The nurse is caring for a woman who had a hysterectomy this morning. Four hours later the woman is unable to urinate. What assessment would determine bladder distention and be comfortable for the patient?
a. Palpate for bladder distention.
b. Percuss the bladder for fullness.
c. Perform a scratch test.
d. Palpate for rebound tenderness.
ANS: C
Assess bladder fullness using Doppler monitoring or scratch test (listening with a stethoscope, lightly scratch abdomen as you move downward from xiphoid until you hear change in sound indicating the top of the bladder). Palpation and percussion can be uncomfortable near an incision and over a full bladder.
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