HESI RN Medical Surgical Nursing | Nurselytic

Questions 57

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HESI RN Medical Surgical Nursing Questions

Extract:

Nurses' Notes
0900
The 54-year-old female client returned to room from postanesthesia care unit (PACU). Situation- background-assessment-recommendation (SBAR) communication reveals client has had no urine output during the anesthesia recovery period. Last void was 8 hours ago. Client positioned in bed. Warm blanket applied for comfort. IV fluids infusing.
1045
Client requesting pain medication and says has the urge to void. Wishes to use bedpan. Voided 75 mL.
1130
Client informs she continues to have the urge to void and feels, "Wet." Placed on bedpan. Voided 50 mL. Bladder palpated and feels full. Bladder scanner applied and revealed 600 mL residual urine.


Question 1 of 5

The nurse is planning care for the client. Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Actions to Take Choices A. Request prescription for external catheter device B. Request prescription for straight catheter C. Insert indwelling urinary catheter D. Assist client to bathroom for voiding E. Increase the IV fluid rate
Potential Condition Choices A. Urinary Retention B. Urinary tract obstruction C. Overflow Urinary Incontinence D. IV fluid intake E. Frequency of voiding
Parameters to monitor Choices A. Amount of urine output B. Residual urine C. Pain medication effects D. IV fluid intake E. Frequency of voiding

Correct Answer: A

Rationale: Urinary retention, indicated by high residual urine, requires straight and indwelling catheters, with monitoring of urine output and residual urine.

Extract:


Question 2 of 5

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Question 3 of 5

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Question 4 of 5

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Question 5 of 5

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