The nurse is caring for a postoperative patient whose urinary catheter was removed 8 hours previously. The patient has not been able to void since the catheter was removed and now reports suprapubic pain. What is the priority action of the nurse?
a. Encourage oral fluid intake and administer a diuretic.
b. Obtain a urine sample to test for culture and sensitivity.
c. Carefully calculate the patient's daily intake and output.
d. Obtain an order to straight-catheterize the patient.
ANS: D
The patient who has not voided for 8 hours after urinary catheter removal and is complaining of suprapubic pain has acute urinary retention. The physician should be notified to obtain an order for straight catheterization to drain the bladder. A urine sample for culture and sensitivity is not ordered. Encouraging fluid intake and administering a diuretic will increase the amount of urine in the bladder and make the patient even more uncomfortable.
You might also like to view...
The nurse is caring for a patient in acute kidney injury. Which of the following complications would most clearly warrant the administration of polystyrene sulfonate (Kayexalate)?
A) Hypernatremia B) Hypomagnesemia C) Hyperkalemia D) Hypercalcemia
The nursing instructor is discussing cardiomyopathies with the junior nursing class. The instructor asks the students to work through a plan of care for a patient with a cardiomyopathy
What priority outcomes does the instructor tell the students should be included in the care plan for these patients? A) Absence of complications B) Adherence to the self-care program C) Improved cardiac output D) Increased activity tolerance
A 40-year-old man who has a mother who was diagnosed with breast cancer at age 45, a father who was diagnosed with smoking-related lung cancer at age 55, a 33-year-old sister with breast cancer, and a 38-year-old sister with ovarian cancer, asks if
he should be con-cerned for his cancer risk. What is the nurse's best response? A. "Your risk is not affected by this family history, because most of the cancers arose in female sex-associated tissues." B. "You have two first-degree relatives and two second-degree relatives with cancer, which increases your general risk for cancer." C. "Your risk for breast cancer is increased; however, your risk for lung cancer is not affected by this history." D. "Your risk for cancer is affected by your parents' cancer development; your sis-ters' cancers have no bearing on your risk."
Regardless of the mother's hepatitis B surface antigen status, all newborns should receive their first vaccination against hepatitis B:
a. Within 12 hours of birth b. At 1 year of age c. At 6 months of age d. At 6 years of age