Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has not voided for 8 hr following the removal of an indwelling urinary catheter. Which of the following actions should be the nurse take first?
A. Provide assistance to bathroom.
Providing assistance to the bathroom is appropriate but should follow assessment and intervention for urinary retention.
B. Increase fluids.
Increasing fluids may be beneficial but does not address the immediate need to assess for urinary retention.
C. Perform a bladder scan.
Performing a bladder scan is the first action to assess if the client has urine in the bladder and needs further intervention.
D. Insert a straight catheter.
Inserting a straight catheter is a potential intervention but should be based on assessment findings from the bladder scan.
This question is an excerpt from Nurse Dive's nursing test bank - Ati med surg pharm comprehensive proctored exam. Take the full exam now
Full Explanation
A. Providing assistance to the bathroom is appropriate but should follow assessment and intervention for urinary retention.
B. Increasing fluids may be beneficial but does not address the immediate need to assess for urinary retention.
C. Performing a bladder scan is the first action to assess if the client has urine in the bladder and needs further intervention.
D. Inserting a straight catheter is a potential intervention but should be based on assessment findings from the bladder scan.
Similar Questions
A nurse is educating coworkers about how to minimize back strain and avoid repeated episodes of low back pain. Which of the following strategies should the nurse include? (Select all that apply.)
A. Sleep on a soft mattress.
Sleeping on a firm mattress is generally recommended to support the spine and prevent back strain.
B. Avoid prolonged sitting.
Avoiding prolonged sitting helps reduce pressure on the lower back and can prevent back pain.
C. Apply heat for 10 min every hour.
Applying heat intermittently can provide temporary relief but does not prevent back strain.
D. Sleep in a side-lying position with flexed knees.
Sleeping in a side-lying position with knees flexed helps maintain natural spinal curvature and reduces strain on the back.
E. Try padded shoe insoles.
Padded shoe insoles may provide comfort. Proper arch support can improve posture and reduce stress on the lower back.
Full Explanation
Rationale:
A. Sleeping on a firm mattress is generally recommended to support the spine and prevent back strain.
B. Avoiding prolonged sitting helps reduce pressure on the lower back and can prevent back pain.
C. Applying heat intermittently can provide temporary relief but does not prevent back strain.
D. Sleeping in a side-lying position with knees flexed helps maintain natural spinal curvature and reduces strain on the back.
E. Padded shoe insoles may provide comfort. Proper arch support can improve posture and reduce stress on the lower back.
A nurse is caring for a group of clients. Which of the following clients should the nurse refer to a social worker? (Select all that apply.)
A. A client who requests to obtain information on the adverse effects of antidepressant medication therapy.
Providing information on medication effects is within the nurse's scope of practice and does not typically require social work involvement.
B. A client who requests to get school assignments while hospitalized on a pediatric unit.
Client B, who is hospitalized and wishes to keep up with school assignments, may need assistance with educational continuity plans.
C. A client who requests to secure an emergency notification system in the home.
Securing an emergency notification system involves social services to assess and arrange appropriate services.
D. A client who requests to receive additional instructions on breastfeeding prior to discharge.
Providing breastfeeding instructions is part of nursing care and does not typically require social work involvement.
E. A client who requires placement in an assisted living facility.
Placement in an assisted living facility requires social work assistance to coordinate appropriate care and transition.
Full Explanation
A. Providing information on medication effects is within the nurse's scope of practice and does not typically require social work involvement.
B. Client B, who is hospitalized and wishes to keep up with school assignments, may need assistance with educational continuity plans.
C. Securing an emergency notification system involves social services to assess and arrange appropriate services.
D. Providing breastfeeding instructions is part of nursing care and does not typically require social work involvement.
E. Placement in an assisted living facility requires social work assistance to coordinate appropriate care and transition.
A nurse on a medical-surgical unit is caring for a client.
Full Explanation
The client is at risk for developing pressure injury and foot drop. Given the client's history of a recent cerebrovascular accident (CVA) and the inability to reposition themselves, there is a heightened risk for pressure injuries due to prolonged periods of immobility. Additionally, the observed occasional movement of the left arm and leg with the right side without movement suggests a potential for muscle weakness or paralysis, which can lead to foot drop, characterized by difficulty in lifting the front part of the foot.