The nurse is caring for a patient recovering from a hysterectomy earlier in the day. Four hours later, the woman is unable to urinate. What assessment should the nurse use to determine bladder distention and be comfortable for the patient?
a. Perform a scratch test.
b. Palpate for bladder distention.
c. Palpate for rebound tenderness.
d. Percuss the bladder for fullness.
ANS: A
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). B. C. D. Palpation and percussion can be uncomfortable near an incision and over a full bladder.
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