The nurse is caring for a client who has a history of urine reflux. To assess the client for this urinary complication, which nursing action is best?
A) Ask the client if voiding sufficient quantities has been a problem.
B) Monitor the client's intake and output for inconsistency.
C) Have the client void into a collection device.
D) Palpate the client's bladder for distension.
D
Feedback:
Normally, urine flows in one direction because of peristaltic action and because the ureters enter the bladder at an oblique angle. The reflux of urine (urine that flows backward) can occur secondary to a distended bladder. By palpating for bladder distension, the nurse is able to determine that reflux urine traveled back to the bladder instead of traveling from the bladder down the urethra. All of the other options provide data that can be helpful, but actually feeling for the distension is best. Using a bladder scanner would also provide an amount of urine in the bladder.
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