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The client voided 300 mL after having an indwelling urinary catheter removed six hours ago. A bladder scan immediately after the void showed that the client has a postvoid residual (PVR) volume of 250 mL. What should the nurse conclude from this finding?
- A. This is an expected finding following catheter removal.
- B. The client's bladder function is approximately 50% of normal.
- C. The bladder scan was not done within 20 minutes of voiding.
- D. The PVR volume is evidence of incomplete bladder emptying.
Correct Answer: D
Rationale: D: A PVR of 250 mL indicates incomplete bladder emptying, as normal PVR is less than 50 mL. A: High PVR is not expected. B: PVR doesn't quantify bladder function percentage. C: No evidence suggests timing was incorrect.
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The hydraulic lift (Hoyer lift) is:
- A. used for all clients who've had orthopedic surgery.
- B. used for all clients who are not able to stand and for extremely obese clients.
- C. used for all clients, both old and young, in a hospital setting.
- D. not an assistive device for special needs.
Correct Answer: B
Rationale: The hydraulic lift is used for safe transfer when a client is not able to stand or is too heavy for the health care workers to lift safely.
Which of the following statements indicates that the nurse understands how to promote rest and sleep for the client?
- A. If you would prefer to not be disturbed, we can postpone all vital signs and assessments until tomorrow morning.
- B. With your physical therapy appointments, you cannot nap more during the day even if your sleep is often interrupted at nighttime.
- C. I can try to incorporate any sleep rituals or an ideal bedtime into your routine.
- D. We cannot group together medications, assessments, and other interventions so you may have multiple interruptions at night.
Correct Answer: C
Rationale: To promote rest and sleep, the nurse should try to incorporate any client preferences into the evening routine.
The client has dentures, including both upper and lower plates. Which technique should the nurse use to correctly perform oral hygiene for this client?
- A. Wear sterile gloves to remove the lower plate first and then the upper plate.
- B. Use a foam swab to pry the upper and lower plates loose before removing these.
- C. Grasp the upper plate at the front teeth with a piece of gauze and move it prior to removal.
- D. Leave the dentures in the client's mouth and use a toothbrush to brush both denture plates.
Correct Answer: C
Rationale: C: Grasping the upper plate and moving it breaks the suction that holds the plate on the roof of the client's mouth. A: Removing denture plates is a clean procedure, and sterile gloves are not necessary. B: Removing the denture plates with a foam swab to pry the plate could injure the client. D: Dentures must be removed to properly clean the client's mouth and the dentures.
The postoperative male client has been unable to urinate into the urinal while lying in bed. Which interventions are appropriate to promote voiding for this client who is to be discharged home within a few hours? Select all that apply.
- A. Have the client apply an external condom catheter while lying flat in bed
- B. Assist the client to stand at the bedside to attempt to urinate in a urinal.
- C. Administer a prescribed analgesic if the client is experiencing pain.
- D. Turn on running water so it is heard while the client attempts to void.
- E. Ask the client to imagine being at home and voiding in his own bathroom.
Correct Answer: B,C,D,E
Rationale: B: Standing mimics normal voiding position. C: Pain relief aids relaxation for voiding. D: Running water stimulates the voiding reflex. E: Guided imagery promotes relaxation. A: Condom catheters manage incontinence, not promote voiding.
A nurse assesses a 83 year-old female's venous ulcer for the second time that is located near the right medial malleolus. The wound is exhibiting purulent drainage and the patient has limited mobility in her home. Which of the options is the best course of action?
- A. Encourage warm water soaks to the right foot.
- B. Notify the case manager of the purulent drainage.
- C. Determine the patient's pulse in the right ankle.
- D. Recommend increased activity to reduce the purulent drainage.
Correct Answer: A
Rationale: A determination of arterial blood flow should be made, prior to encouraging increased activity, or notifying additional team members.