A client has just voided 50 mL,yet reports that his bladder still feels full.The nurse's next actions should include which of the following? Select all that apply.
A) Palpating the bladder height
B) Obtaining a clean-catch urine specimen
C) Performing a bladder scan
D) Asking the patient about his recent voiding history
E) Inserting a straight catheter to measure residual urine

Question

Quizplus · Accepted Answer

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."
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.

A Client Has Just Voided 50 ML,yet Reports That His