Answer to Question 1
A, C, D
The nurse should palpate the bladder for distention to validate the client's statement. A bladder scan will yield a more accurate measurement of the postvoid residual urine, so it would be appropriate at this time. A detailed history of the client's recent voiding patterns will assist the nurse in determining the appropriate nursing diagnosis and developing a plan of care. A clean-catch urine specimen may be necessary if further assessment shows the potential of a urinary tract infection, but is not indicated at this time. Inserting a straight catheter to measure residual urine is an invasive procedure with the risk of introducing microorganisms into the bladder. It is usually unnecessary if the nurse has access to a portable bladder scanner.
Answer to Question 2
B, C
The nurse should encourage lifestyle changes such as maintaining daily oral fluid intake to 8 to 10 glasses per day. Citrus is considered a bladder irritant; intake should be reduced or eliminated. Caffeine also irritates the bladder; intake should be limited to less than 100 mg per day. High-impact exercise can be associated with stress incontinence for those with weakened pelvic muscles that support the bladder and urethra, so it should not be a goal for this patient. The patient with incontinence needs to drink adequate fluids and not limit fluids. Adequate fluid intake is important to maintain dilute urine, which is less irritating to the bladder; to maintain systemic hydration; and to reduce the risk for constipation, which can contribute to urinary incontinence
When using an interpreter, the nurse should pose questions directly to the patient, not the interpre
C, A nurse can also administer the medication by setting the dose and rate with an electronic infusi
The nurse applies a pulse oximeter sensor on the client’s finger.
Nurse administering enteral nutrition through a feeding tube.
Measuring the client’s height with a platform scale
Testing patellar reflex, client in a supine position