A older patient recovering from total hip replacement surgery 8 hours ago has not been able to void spontaneously. Which actions should the nurse take to assist this patient?
Select all that apply.
1. Increase fluids.
2. Turn onto the left side.
3. Palpate the bladder for distention.
4. Insert an indwelling urinary catheter.
5. Complete a bladder scan at the bedside.
Correct Answer: 1, 3, 5
: The nurse should promote fluid intake as allowed, monitoring intake and output. Assess for bladder distention if the patient has not voided within 7 to 8 hours after surgery. Use a portable ultrasound scanner to determine the amount of urine in the bladder. Turning onto the left side will not promote urinary elimination. Urinary catheterizations should be avoided to reduce the potential for urinary tract infections and urethral trauma.
You might also like to view...
A patient's catheter bag is empty 2 hours after it was last drained. The nurse's first action is to:
a. Irrigate the catheter b. Perform a bladder scan c. Replace the catheter d. Check for kinks or compression
What is the purpose of the NCLEX-PN®?
1. Protect the public. 2. Pass the top 75 percent of test takers. 3. Ensure knowledge of nursing process. 4. Determine whether the nurse is competent to practice.
In which patient should the nurse be most concerned about immunodeficiency disorder?
a. The patient taking desensitization injections (immunotherapy) b. The patient on long-term radiation therapy for cancer c. The overweight patient d. The patient recently diagnosed with lupus erythematosus
Components of a nursing health history include
a. Current treatment orders. b. Nurse's concerns. c. Nurse's goals for the patient. d. Patient expectations.