Nokea
The nurse is caring for a patient with benign prostatic hyperplasia (BPH) and a markedly distended bladder who is agitated and confused. Which of the following interventions prescribed by the health care provider should the nurse implement first?
- A. Insert a urinary retention catheter.
- B. Schedule an intravenous pyelogram.
- C. Administer lorazepam 0.5 mg PO.
- D. Draw blood for blood urea nitrogen (BUN) and creatinine testing.
Correct Answer: A
Rationale: The patient's history and clinical manifestations are consistent with acute urinary retention, and the priority action is to relieve the retention by catheterization. The BUN and creatinine measurements can be obtained after the catheter is inserted. The patient's agitation may resolve once the bladder distention is corrected, and sedative drugs should be used cautiously in older patients. The IVP is an appropriate test, but does not need to be done urgently.
You may also like to solve these questions
The nurse is caring for a patient who had a nephrectomy after having massive trauma to the kidney. Which of the following assessment findings obtained postoperatively is most important to communicate to the surgeon?
- A. Blood pressure is 102/58.
- B. Incisional pain level is 8/10.
- C. Urine output is 20 ml/hour for 2 hours.
- D. Crackles are heard at both lung bases.
Correct Answer: C
Rationale: Because the urine output should be at least 0.5 ml/kg/hour, a 20 ml output for 2 hours indicates that the patient may have decreased renal perfusion because of bleeding, inadequate fluid intake, or obstruction at the suture site. The blood pressure requires ongoing monitoring but does not indicate inadequate perfusion at this time. The patient should cough and deep breathe, but the crackles do not indicate a need for an immediate change in therapy. The incisional pain should be addressed, but this is not as potentially life-threatening as decreased renal perfusion.
A female patient asks the nurse for a perineal pad, stating that laughing or coughing causes leakage of urine. Which of the following interventions is best to include in the care plan?
- A. Assist the patient to the bathroom q3hr.
- B. Place a commode at the patient's bedside.
- C. Demonstrate how to perform the Credé manoeuvre.
- D. Teach the patient how to perform Kegel exercises.
Correct Answer: D
Rationale: Exercises to strengthen the pelvic floor muscles will help reduce stress incontinence. The Credé manoeuvre is used to help empty the bladder for patients with overflow incontinence. Placing the commode close to the bedside and assisting the patient to the bathroom are helpful for functional incontinence.
After receiving change-of-shift report, which of the following patients should the nurse assess first?
- A. A patient with nephrotic syndrome with massive edema and ascites
- B. A patient with stage 3 chronic kidney disease with complaints of fatigue
- C. A patient with stage 4 chronic kidney disease with complaints of dysuria
- D. A patient with urolithiasis who needs teaching about preventing recurrence
Correct Answer: A
Rationale: The patient with nephrotic syndrome with massive edema and ascites is at risk for complications such as respiratory distress or infection due to fluid overload, making this the priority for assessment. Fatigue and dysuria in chronic kidney disease and teaching needs for urolithiasis are less urgent.
The nurse is providing patient teaching to a patient with cystitis regarding prevention of future urinary tract infections (UTIs). Which of the following patient statements indicate that teaching has been effective?
- A. I can use vaginal sprays to reduce bacteria.
- B. I will drink a litre of water or other fluids every day.
- C. I will wash with soap and water before sexual intercourse.
- D. I will empty my bladder every 2-4 hours during the day.
Correct Answer: D
Rationale: Voiding every 2-4 hours is recommended to prevent UTIs. Use of vaginal sprays is discouraged. The bladder should be emptied before and after intercourse, but cleaning with soap and water is not necessary. A litre of fluids is insufficient to provide adequate urine output to decrease risk for UTI.
The nurse is caring for a patient following rectal surgery who voids about 50 mL of urine every 30-60 minutes. Which of the following nursing actions is best?
- A. Use a bladder scan device to check the postvoiding residual.
- B. Monitor the patient's intake and output over the next few hours.
- C. Have the patient take small amounts of fluid frequently throughout the day.
- D. Reassure the patient that this is normal after rectal surgery because of anesthesia.
Correct Answer: A
Rationale: A bladder scan device can be used to check for residual urine after the patient voids. Because the patient's history and clinical manifestations are consistent with overflow incontinence, it is not appropriate to have the patient drink small amounts. Although overflow incontinence is not unusual after surgery, the nurse should intervene to correct the physiological problem, not just reassure the patient. The patient may develop reflux into the renal pelvis as well as discomfort from a full bladder if the nurse waits to address the problem for several hours.