NCLEX Style Study Question
Correct answer now posted by Tanya…
Twelve hours post lumbar laminectomy a client complains of discomfort and the inability to void. Which is the best action for the nurse to take?
- Assist the client to the bathroom
- Palpate for fullness of the bladder
- Apply manual pressure to the bladder as the client attempts to void
- Insert an indwelling catheter
March 24th, 2006 at 5:35 pm
The best answer is 4. as this will both decrease discomfort as well as aid in fluid exchange. 1 and 3 are not proper interventions in this s/p LL patient , and 2 will not provide for relief of urinary retention 2nd to surgery and anethesia
March 24th, 2006 at 5:36 pm
I’m not sure about laminectomies and when the patient should be able to ambulate, and we can’t put in a catheter w/out dr’s orders so I picked palpate….looking forward to the answer!!!
March 24th, 2006 at 7:50 pm
4. Cath the dude.
March 24th, 2006 at 9:15 pm
I would palpate the abdomen for fullness of the bladder..because this is an assessment. Then afterwards I would get doctor’s order for the catheter. I wouldn’t cath first.
March 25th, 2006 at 3:17 am
# 2 First palpate for fulness of bladder..then insert the foley catheter
March 25th, 2006 at 4:14 am
Since we are answering question base on the text book i use nursing process so the best answer is number (2).what make number (4) wrong because its a invasive procedure.what make (1,2) incorrect because it doesn’t answer the question.
March 25th, 2006 at 4:54 am
# 2 Assess first then intervene.
March 25th, 2006 at 9:50 am
You know that bladder has to be full, assess (palpate) insert cath, inform doc
March 25th, 2006 at 11:43 am
I would assess first so #2.
March 25th, 2006 at 3:43 pm
2
March 27th, 2006 at 6:42 am
likewise… i’d assess first
March 27th, 2006 at 11:00 am
Correct answer: 2
After surgery, urinary retention may occur for may occur for many reasons: anesthesia depresses the micturition reflex arch, voluntary micturition is impeded when the bladder is distended, or the supine position reduces the ability to relax the perineal muscles and external sphincter. If the bladder is distended and conservative measures have not induced voiding, an order for catheterization should be obtained.
March 27th, 2006 at 12:36 pm
#2 I would assess first before doing anything else, then get the doctor’s order to cath the patient.
March 30th, 2006 at 3:18 pm
Assess, assess, assess. That’s what my instructors say all day long. We firsly have to assess for bladder fullness, and than, adding the subjective data from patient, we may intervene in the least invasive way. If not successfull, we need MD order to insert indwelling catheter. I think though that the MD may order in and out cath… not indwelling catheter…
March 30th, 2006 at 3:42 pm
do a bladder scan which can show how much residual in the bladder, if it’s high volume, need inform doctor
April 20th, 2006 at 8:06 pm
assess….. # 2 is the correct answer