Nclexrn Quiz: Elimination And Bowel Bladder Care
20 questions · exam conditions
0:00
Elimination And Bowel Bladder CareQuestion 1 of 20

A 54-year-old male is 8 hours postoperative after an inguinal hernia repair under general anesthesia. History includes benign prostatic hyperplasia. He reports suprapubic pressure and has not voided since surgery; bladder scan shows 780 mL. Vital signs: T 37.0°C (98.6°F), HR 104/min, RR 18/min, BP 148/86 mm Hg; lower abdomen is distended and tender. Which intervention should the nurse implement FIRST?

Encourage oral fluids and assist the client to stand at the bedside to attempt to void
Insert a straight catheter using sterile technique per postoperative urinary retention protocol
Request a prescription for tamsulosin and administer the first dose
Reassess the bladder volume with a repeat bladder scan in 1 hour
← Back to quizzes

Nclexrn Quiz

Nclexrn Quiz: Elimination And Bowel Bladder Care

Practice Elimination And Bowel Bladder Care in Nclexrn with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.

What this quiz covers

This quiz focuses on Elimination And Bowel Bladder Care, giving you a quick way to practice the rules, question types, and explanations that matter most for Nclexrn.

How to use this quiz

Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.

All questions

Question 1

A 54-year-old male is 8 hours postoperative after an inguinal hernia repair under general anesthesia. History includes benign prostatic hyperplasia. He reports suprapubic pressure and has not voided since surgery; bladder scan shows 780 mL. Vital signs: T 37.0°C (98.6°F), HR 104/min, RR 18/min, BP 148/86 mm Hg; lower abdomen is distended and tender. Which intervention should the nurse implement FIRST?

  1. Encourage oral fluids and assist the client to stand at the bedside to attempt to void
  2. Insert a straight catheter using sterile technique per postoperative urinary retention protocol (correct answer)
  3. Request a prescription for tamsulosin and administer the first dose
  4. Reassess the bladder volume with a repeat bladder scan in 1 hour
Explanation: This question tests clinical judgment in elimination and bowel/bladder care. The key nursing concept is priority intervention for acute urinary retention to prevent complications like bladder damage or infection. Inserting a straight catheter using sterile technique per postoperative urinary retention protocol is the best choice because the bladder volume of 780 mL indicates severe retention requiring immediate relief, especially with symptoms of suprapubic pressure, distension, tenderness, tachycardia, and hypertension. Encouraging oral fluids and assisting to stand (A) is less appropriate as it delays relief and may not overcome retention due to BPH and anesthesia effects; requesting tamsulosin (C) is incorrect as it takes time to act and does not address immediate retention; reassessing in 1 hour (D) delays intervention and risks further complications. The underlying nursing principle is patient safety by promptly addressing acute retention to avoid autonomic dysreflexia or renal backflow. Effective clinical judgment involves using protocols for timely catheterization in high-risk postoperative clients. A transferable strategy is to always assess bladder volume and symptoms promptly in postoperative clients with risk factors like BPH, intervening per protocol to prevent urinary complications.

Question 2

A 26-year-old female is 6 weeks postpartum and reports ongoing urine leakage with exercise. She asks when she should call the provider. Assessment: afebrile; denies dysuria; no pelvic pain. Which assessment should the nurse PRIORITIZE?

  1. Assess for symptoms of urinary tract infection, including dysuria, urgency, and fever (correct answer)
  2. Assess the client's preferred brand of incontinence pads
  3. Assess the client's newborn feeding schedule
  4. Assess the client's understanding of the newborn's immunization schedule
Explanation: This question tests clinical judgment in elimination and bowel/bladder care. The key nursing concept is assessing for complications like UTI in postpartum incontinence. Assessing for symptoms of urinary tract infection, including dysuria, urgency, and fever, is the best choice because it prioritizes ruling out infection in a client with ongoing leakage at 6 weeks postpartum who asks about calling the provider. Assessing preferred pads (B), newborn feeding (C), or immunizations (D) are unrelated to elimination concerns. The underlying nursing principle is safety by identifying infection early. Effective assessment focuses on UTI red flags. A transferable strategy is to evaluate for infection symptoms in postpartum clients with persistent incontinence before addressing other self-care aspects.

Question 3

A 28-year-old female is 2 days postpartum after a vaginal delivery. She reports leaking urine when coughing and laughing. History: no prior urinary problems. Assessment: T 36.9°C (98.4°F), HR 82/min, RR 16/min, BP 118/72 mm Hg; perineum intact; fundus firm; no dysuria or fever. Which intervention should the nurse implement FIRST?

  1. Teach pelvic floor (Kegel) exercises and establish a bladder training schedule (correct answer)
  2. Insert an indwelling urinary catheter for 48 hours to rest the bladder
  3. Request a prescription for anticholinergic medication to reduce bladder spasms
  4. Limit oral fluids to decrease urinary leakage
Explanation: This question tests clinical judgment in elimination and bowel/bladder care. The key nursing concept is non-invasive interventions for postpartum stress incontinence to promote bladder control. Teaching pelvic floor (Kegel) exercises and establishing a bladder training schedule is the best choice because it addresses stress incontinence through strengthening muscles and scheduled voiding, suitable for early postpartum without complications. Inserting an indwelling catheter (B) is invasive and risks infection; requesting anticholinergic medication (C) is inappropriate for stress incontinence; limiting fluids (D) risks dehydration. The underlying nursing principle is promoting self-management and safety by avoiding invasive measures. Effective education empowers postpartum clients with exercises for long-term continence. A transferable strategy is to initiate conservative management like Kegels and bladder training for new-onset stress incontinence in postpartum women before considering medications or devices.

Question 4

A 41-year-old male in rehab with neurogenic bladder is practicing clean intermittent catheterization. He asks how to reduce urinary tract infection risk at home. Which client statement indicates understanding of self-care for elimination?

  1. "If my urine looks cloudy, I will catheterize less often to avoid irritation."
  2. "I will wash my hands before catheterizing and clean the genital area each time." (correct answer)
  3. "I will keep my urine in the bladder as long as possible to train it to hold more."
  4. "I will stop drinking fluids after dinner every day to prevent infection."
Explanation: This question tests clinical judgment in elimination and bowel/bladder care. The key nursing concept is infection prevention education for self-catheterization in neurogenic bladder. The statement 'I will wash my hands before catheterizing and clean the genital area each time' is the best choice because it demonstrates proper hygiene to reduce UTI risk in a client practicing intermittent catheterization. Catheterizing less if urine is cloudy (A) ignores infection signs; keeping urine in bladder longer (C) risks overdistension; stopping fluids after dinner (D) causes dehydration. The underlying nursing principle is client education on aseptic technique. Effective teaching emphasizes handwashing and cleaning. A transferable strategy is to reinforce hygiene protocols in clients learning self-catheterization to minimize infection risks at home.

Question 5

A 71-year-old male in long-term care has chronic constipation and is newly prescribed docusate sodium daily. He asks what it will do. Which client statement indicates understanding of self-care for elimination?

  1. "This medicine will soften my stool so it is easier to pass without straining." (correct answer)
  2. "This medicine will cause an immediate bowel movement within 15 minutes."
  3. "I should stop drinking fluids while taking this medicine."
  4. "I should take this only when I have severe abdominal pain."
Explanation: This question tests clinical judgment in elimination and bowel/bladder care. The key nursing concept is client education on stool softeners for chronic constipation management. The statement 'This medicine will soften my stool so it is easier to pass without straining' is the best choice because it correctly describes docusate's action in an elderly client newly prescribed it. Causing immediate bowel movement (B) is incorrect as it's not a stimulant; stopping fluids (C) is wrong; taking only for severe pain (D) misuses it. The underlying nursing principle is accurate medication education. Effective teaching clarifies purpose and timing. A transferable strategy is to explain stool softeners' softening effect to clients with chronic constipation to promote adherence and prevent straining.

Question 6

An 80-year-old female in long-term care has chronic constipation and is ordered a sodium phosphate enema as needed. History includes chronic kidney disease stage 4 and heart failure. She has not had a bowel movement for 5 days and reports rectal pressure. Vital signs: T 36.6°C (97.9°F), HR 84/min, RR 18/min, BP 136/78 mm Hg. The nurse should QUESTION which order related to elimination care?

  1. Administer sodium phosphate enema as needed for constipation (correct answer)
  2. Encourage toileting after breakfast to use the gastrocolic reflex
  3. Increase dietary fiber as tolerated
  4. Encourage ambulation or chair activity as tolerated
Explanation: This question tests clinical judgment in elimination and bowel/bladder care. The key nursing concept is safety in laxative use for clients with comorbidities like kidney disease. The nurse should question administering sodium phosphate enema as needed for constipation because it risks electrolyte imbalances and phosphate toxicity in a client with stage 4 CKD and heart failure. Encouraging toileting after breakfast (B) uses gastrocolic reflex safely; increasing fiber (C) is appropriate; encouraging ambulation (D) promotes motility. The underlying nursing principle is avoiding high-risk interventions in vulnerable clients. Effective judgment considers contraindications. A transferable strategy is to review comorbidities like renal impairment before administering phosphate-based enemas in elderly clients with constipation.

Question 7

A 30-year-old female is 1 day postpartum after a prolonged labor with epidural anesthesia. She reports difficulty initiating urination and feels bladder fullness. Assessment: T 36.8°C (98.2°F), HR 90/min, RR 16/min, BP 116/70 mm Hg; fundus deviated to the right; lochia is moderate. Which intervention should the nurse implement FIRST?

  1. Assist the client to the bathroom and use measures to stimulate voiding (running water, peri-bottle warm water) (correct answer)
  2. Administer a prescribed anticholinergic medication such as oxybutynin to decrease bladder spasms and promote complete bladder emptying
  3. Limit oral fluids until the client can void independently to reduce bladder distention and prevent overfilling
  4. Request a prescription for an indwelling catheter for 5 days to ensure complete bladder emptying and prevent overdistention
Explanation: The safest first action is to help this client use natural voiding cues. Assisting her to the bathroom and using sensory stimulation—running water or warm peri-bottle water—can trigger the micturition reflex and often relieves postpartum urinary retention before any invasive step is needed. The anticholinergic option is not appropriate because these medications reduce detrusor contractility and can make retention worse; they are used for overactive bladder, not impaired emptying. Limiting oral fluids is also incorrect: withholding fluids does not reduce the bladder distention caused by retention, and the client needs hydration to maintain urine output and prevent infection. Requesting an indwelling catheter for 5 days is too invasive for the first response; it raises infection risk and should be reserved for failure of conservative measures or severe obstruction. The priority is to attempt low-risk, non-invasive voiding stimulation first and reassess before escalating.

Question 8

A 43-year-old male in rehab with neurogenic bladder is being discharged with a plan for clean intermittent self-catheterization. He asks how often to catheterize. Assessment: stable vital signs; last bladder scan before catheterization was 520 mL. Which teaching should the nurse provide to support safe elimination?

  1. Catheterize on a consistent schedule to keep bladder volumes generally below about 400–500 mL (correct answer)
  2. Catheterize only when you feel bladder fullness to avoid overuse
  3. Drink as little fluid as possible so catheterization is rarely needed
  4. Sterilize the catheter with bleach solution before each use
Explanation: This question tests clinical judgment in elimination and bowel/bladder care. The key nursing concept is client education for safe self-catheterization scheduling in neurogenic bladder. Teaching to catheterize on a consistent schedule to keep bladder volumes generally below about 400–500 mL is the best choice because it prevents overdistension and complications in a discharging client with prior 520 mL scan. Catheterizing only on fullness (B) risks high volumes; drinking little fluid (C) causes dehydration; sterilizing with bleach (D) is unsafe. The underlying nursing principle is education for complication prevention. Effective teaching sets volume limits. A transferable strategy is to educate on scheduled catheterization based on individual volumes for clients with neurogenic bladder to maintain bladder health at home.

Question 9

A 69-year-old male is 4 hours postoperative after colon resection. He has not voided and reports suprapubic pain. Bladder scan shows 410 mL. Vital signs: T 36.7°C (98.1°F), HR 92/min, RR 16/min, BP 138/78 mm Hg. Which intervention should the nurse implement FIRST?

  1. Provide privacy and assist the client to a normal voiding position, then reassess output (correct answer)
  2. Insert a straight catheter immediately and document the output to relieve the bladder distention
  3. Request a prescription for a bladder ultrasound to confirm retention before selecting an intervention
  4. Administer a prescribed laxative to reduce abdominal pressure and relieve the suprapubic discomfort
Explanation: The client is 4 hours post-colon resection, has not voided, reports suprapubic pain, and the bladder scan measures 410 mL—moderate postoperative urinary retention. The first-line nursing action is the least invasive measure that can promote voiding. Providing privacy and assisting the client to a normal voiding position encourages natural micturition, and reassessing output afterward tells you whether that measure worked before you escalate. Inserting a straight catheter immediately obtains urine but bypasses a simple, safe first step and exposes the client to unnecessary instrumentation. Requesting a bladder ultrasound to confirm retention is redundant: the scan already documented 410 mL, so this delays care and does nothing to relieve the distention. Administering a laxative addresses bowel function, not bladder emptying, and is unrelated to the retention. In elimination care, use a stepwise approach: try positioning, privacy, and comfort measures, reassess, and move to catheterization only if the client still cannot void.

Question 10

A 45-year-old female is 10 hours postoperative after laparoscopic cholecystectomy. She has not voided since surgery and reports increasing suprapubic discomfort. Bladder scan shows 520 mL; urine output since arrival to PACU is 0 mL. Vital signs: T 36.8°C (98.2°F), HR 102/min, RR 16/min, BP 146/84 mm Hg. Which intervention should the nurse implement FIRST?

  1. Assist the client to the bathroom and provide privacy, running water if needed (correct answer)
  2. Insert an indwelling urinary catheter and leave it in place for 24 hours
  3. Request a prescription for a diuretic to stimulate urine production
  4. Encourage the client to restrict fluids until able to void
Explanation: This question tests clinical judgment in elimination and bowel/bladder care. The key nursing concept is non-invasive stimulation for postoperative urinary retention to promote natural voiding. Assisting the client to the bathroom and providing privacy, running water if needed, is the best choice because it uses normal positioning and sensory cues to facilitate voiding in a client with 520 mL retention and suprapubic discomfort post-cholecystectomy. Inserting an indwelling catheter (B) is more invasive; requesting a diuretic (C) does not address retention directly; restricting fluids (D) risks dehydration. The underlying nursing principle is promoting physiological voiding and safety by avoiding unnecessary catheterization. Effective intervention starts with least invasive methods. A transferable strategy is to use environmental cues like privacy and running water as first-line for postoperative clients with moderate urinary retention before invasive options.

Question 11

A 66-year-old male is 9 hours postoperative after spinal surgery. He reports inability to void and severe suprapubic discomfort. Bladder scan shows 720 mL. Vital signs: T 37.0°C (98.6°F), HR 108/min, RR 18/min, BP 150/88 mm Hg. Which assessment should the nurse PRIORITIZE before implementing the next intervention?

  1. Assess for allergies to latex and iodine or chlorhexidine prior to catheterization (correct answer)
  2. Assess the client's usual number of voids per day at home
  3. Assess the client's understanding of postoperative mobility restrictions
  4. Assess the client's preference for using a urinal versus a bedside commode
Explanation: This question tests clinical judgment in elimination and bowel/bladder care. The key nursing concept is safety assessment before catheterization for urinary retention. Assessing for allergies to latex and iodine or chlorhexidine prior to catheterization is the best choice because it prevents allergic reactions during the procedure in a postoperative client with 720 mL retention and discomfort. Assessing usual voids (B), understanding mobility (C), or preference for urinal (D) are less immediate than allergy checks. The underlying nursing principle is patient safety through pre-procedure screening. Effective assessment prioritizes allergies. A transferable strategy is to always screen for allergies to catheter materials and antiseptics before urinary interventions in surgical clients.

Question 12

A 62-year-old female is postoperative day 0 after hysterectomy. She has an order for intermittent catheterization for urinary retention if bladder scan is greater than 600 mL. She reports discomfort and inability to void; bladder scan shows 650 mL. Which intervention should the nurse implement FIRST?

  1. Perform intermittent catheterization using sterile technique and measure output (correct answer)
  2. Encourage the client to drink 1 liter of water quickly to stimulate urination
  3. Re-scan the bladder in 2 hours to confirm urinary retention
  4. Request a prescription for an indwelling catheter for the remainder of hospitalization
Explanation: This question tests clinical judgment in elimination and bowel/bladder care. The key nursing concept is following protocols for postoperative urinary retention relief. Performing intermittent catheterization using sterile technique and measuring output is the best choice because the bladder scan of 650 mL exceeds the 600 mL threshold per order, with discomfort and inability to void post-hysterectomy. Encouraging quick fluid intake (B) risks overdistension; re-scanning in 2 hours (C) delays; requesting indwelling (D) alters the order. The underlying nursing principle is adherence to evidence-based protocols for safety. Effective intervention relieves retention promptly. A transferable strategy is to use ordered thresholds for catheterization in postoperative clients to prevent bladder injury.

Question 13

A 67-year-old male is 6 hours postoperative after total hip arthroplasty with spinal anesthesia and opioid analgesia. He reports severe lower abdominal pressure and inability to void. Bladder scan shows 620 mL. Vital signs: T 36.7°C (98.1°F), HR 96/min, RR 14/min, BP 140/80 mm Hg. The nurse receives these orders: (1) Straight catheterize now and record output; (2) Encourage oral fluids; (3) Apply warm compress to suprapubic area; (4) Administer morphine 4 mg IV now for pain. The nurse should QUESTION which order related to elimination care?

  1. Straight catheterize now and record output
  2. Encourage oral fluids
  3. Apply warm compress to the suprapubic area
  4. Administer morphine 4 mg IV now for pain (correct answer)
Explanation: This question tests clinical judgment in elimination and bowel/bladder care. The key nursing concept is safety in managing postoperative urinary retention while considering pain's impact on voiding. The nurse should question administering morphine 4 mg IV now for pain because opioids can worsen urinary retention by relaxing the bladder and increasing sphincter tone, exacerbating the issue in this postoperative client with 620 mL retention. Straight catheterizing now (A) is appropriate to relieve retention; encouraging fluids (B) supports hydration; applying warm compress (C) may aid voiding. The underlying nursing principle is avoiding interventions that could worsen retention, prioritizing pain management alternatives. Effective judgment involves recognizing opioid side effects on elimination. A transferable strategy is to assess pain and retention together in postoperative clients, questioning opioids if they may impair voiding and opting for non-opioid alternatives.

Question 14

A 40-year-old male in inpatient rehab with neurogenic bladder is learning self-catheterization. The nurse observes him preparing supplies. Which action by the client requires the nurse to intervene to prevent infection?

  1. Cleansing the genital area before inserting the catheter
  2. Using clean technique and keeping the catheter tip from touching the sink
  3. Applying lubricant to the catheter before insertion
  4. Placing the catheter on the bed linens before insertion (correct answer)
Explanation: This question tests clinical judgment in elimination and bowel/bladder care. The key nursing concept is infection prevention during self-catheterization for neurogenic bladder. The action of placing the catheter on the bed linens before insertion requires intervention because it contaminates the catheter, increasing infection risk in a client learning the procedure. Cleansing the genital area (A), using clean technique (B), and applying lubricant (C) are correct steps. The underlying nursing principle is maintaining sterility to prevent UTIs. Effective observation corrects unsafe practices. A transferable strategy is to intervene on contamination risks during teaching self-catheterization to ensure safe home practice.

Question 15

A 79-year-old female in a long-term care facility has chronic constipation (bowel movement every 4–5 days). History includes hypothyroidism and osteoarthritis; she takes iron and a calcium supplement. She reports no bowel movement for 6 days, decreased appetite, and abdominal discomfort. Assessment: T 36.8°C (98.2°F), HR 88/min, RR 16/min, BP 132/74 mm Hg; abdomen is firm with hypoactive bowel sounds; rectal exam reveals hard stool in the rectal vault. Which intervention should the nurse implement FIRST?

  1. Increase dietary fiber and encourage 2–3 L/day of fluids as tolerated
  2. Administer a prescribed stool softener and reassess in the morning
  3. Administer a prescribed suppository or enema to relieve suspected fecal impaction (correct answer)
  4. Request a prescription to discontinue the iron supplement
Explanation: This question tests clinical judgment in elimination and bowel/bladder care. The key nursing concept is priority intervention for suspected fecal impaction to relieve discomfort and prevent complications like obstruction. Administering a prescribed suppository or enema to relieve suspected fecal impaction is the best choice because the rectal exam reveals hard stool in the vault, indicating impaction needing immediate disimpaction, with symptoms of no bowel movement for 6 days, decreased appetite, abdominal discomfort, firm abdomen, and hypoactive bowel sounds. Increasing dietary fiber and fluids (A) is less appropriate as it does not address acute impaction; administering a stool softener and reassessing in the morning (B) delays relief; requesting to discontinue iron (D) is incorrect as it does not immediately resolve the impaction. The underlying nursing principle is safety by prioritizing relief of impaction to avoid perforation or further complications. Effective client care involves assessing for impaction signs like hard stool on rectal exam. A transferable strategy is to perform a rectal exam in elderly clients with chronic constipation and prolonged no bowel movement, intervening promptly with disimpaction methods.

Question 16

A 38-year-old male is in inpatient rehabilitation after a T12 spinal cord injury with neurogenic bladder. He is learning clean intermittent self-catheterization. He says he is worried about infection risk. Current assessment: afebrile, denies dysuria; urine is clear; intake is adequate. Which client statement indicates understanding of self-care for elimination?

  1. "I will reuse the same catheter for a week without cleaning it to save supplies."
  2. "I will catheterize on a regular schedule and keep my bladder volumes from getting too high." (correct answer)
  3. "I will stop drinking fluids after lunch so I do not have to catheterize as often."
  4. "I will take antibiotics every day to prevent urinary tract infections."
Explanation: This question tests clinical judgment in elimination and bowel/bladder care. The key nursing concept is effective client education for self-management of neurogenic bladder to prevent complications like infection. The statement 'I will catheterize on a regular schedule and keep my bladder volumes from getting too high' is the best choice because it demonstrates understanding of preventing overdistension and infection risk through scheduled clean intermittent catheterization. Reusing the same catheter without cleaning (A) is incorrect as it increases infection risk; stopping fluids after lunch (C) risks dehydration; taking antibiotics daily (D) promotes resistance and is not standard. The underlying nursing principle is client education on infection prevention and bladder management. Effective teaching ensures clients understand scheduling to maintain low bladder volumes. A transferable strategy is to reinforce scheduled catheterization and monitoring for infection signs in clients with neurogenic bladder during rehabilitation.

Question 17

A 77-year-old male with chronic constipation is admitted from home for dehydration. He reports no bowel movement for 8 days and severe rectal pressure. Assessment: T 37.1°C (98.8°F), HR 96/min, RR 18/min, BP 110/64 mm Hg; abdomen mildly distended; rectal exam shows a large amount of hard stool. Which intervention should the nurse implement FIRST?

  1. Administer prescribed polyethylene glycol and reassess bowel movement in 24 hours before adding other laxatives
  2. Prepare to administer a prescribed enema or suppository to relieve fecal impaction (correct answer)
  3. Teach the client to increase dietary fiber to 30 g/day and schedule a bowel program
  4. Request a prescription for abdominal computed tomography to evaluate the bowel before initiating treatment
Explanation: The client's rectal findings and eight days without a bowel movement point to fecal impaction. Severe rectal pressure and a large amount of hard stool mean the first priority is to relieve the mass. Preparing a prescribed enema or suppository is the correct first step because it directly treats the impaction. Administering oral polyethylene glycol and waiting 24 hours before another step is slow and may not remove hard stool that is already in the rectal vault. Teaching a higher fiber intake and scheduling a bowel program is long-term prevention, not immediate treatment of an existing impaction. Requesting abdominal CT before intervening adds unnecessary delay when the rectal examination has already identified hard stool. Therefore, the enema or suppository is the best first intervention.

Question 18

A 32-year-old female is 6 hours postpartum after a prolonged labor with epidural anesthesia. She reports inability to void and increasing perineal pressure. Assessment: fundus firm at the umbilicus, moderate lochia, bladder distention noted; vital signs: T 36.7°C (98.1°F), HR 110/min, RR 18/min, BP 118/70 mm Hg. Which intervention should the nurse implement FIRST?

  1. Assist the client to void by providing privacy and running warm water over the perineum (correct answer)
  2. Insert an indwelling catheter and leave it in place for 24 hours to ensure bladder emptying
  3. Request a provider order for a diuretic to stimulate urination and to reduce bladder distention
  4. Measure a post-void residual after the client voids spontaneously to evaluate the completeness of emptying
Explanation: The priority is to use conservative, minimally invasive measures first for postpartum urinary retention after epidural anesthesia. The client has a distended bladder and inability to void, which is common due to temporary loss of bladder sensation. Providing privacy and running warm water over the perineum is a non-invasive technique that often stimulates voiding and should be tried before more invasive interventions. Inserting an indwelling catheter immediately is not the first step because it carries infection risk and is reserved for when conservative measures fail. Requesting a diuretic is not helpful because epidural-related retention is not due to excess fluid but to impaired nerve signaling; a diuretic may even increase urine production and worsen distention. Measuring a post-void residual requires the client to void first, which she has not been able to do, so it is not an immediate action. Therefore, the best first intervention is to assist with voiding using privacy and warm water.

Question 19

A 45-year-old male is 1 day post-op after inguinal hernia repair and has an indwelling urinary catheter. The urine in the drainage bag is cloudy and foul-smelling, but the client is afebrile and denies suprapubic pain. Vital signs: T 36.9°C (98.4°F), HR 82/min, RR 16/min, BP 124/78 mm Hg. Which intervention should the nurse implement FIRST?

  1. Obtain a urine specimen from the sampling port using aseptic technique for urinalysis
  2. Replace the catheter and drainage bag using sterile technique to avoid contamination
  3. Increase oral fluid intake if not contraindicated and ensure unobstructed urine flow (correct answer)
  4. Request a provider order for broad-spectrum antibiotics to treat the suspected infection
Explanation: The client has cloudy, foul-smelling urine but no fever or suprapubic pain, which suggests concentrated urine or bacterial colonization rather than a symptomatic infection. The first action is to promote hydration and ensure unobstructed urine flow, which can flush the system and help prevent progression to infection. Obtaining a urine specimen for urinalysis is premature without systemic signs of infection. Replacing the catheter is unnecessary and increases the risk of infection. Requesting antibiotics is inappropriate without a confirmed infection and could contribute to resistance.

Question 20

A 36-year-old female is 3 days postpartum and reports urinary leakage when she lifts her baby and when she sneezes. She asks how to prevent skin irritation. Assessment: afebrile; perineal skin mildly reddened; no dysuria. Which client statement indicates understanding of self-care for elimination?

  1. I will avoid drinking water so I do not leak urine, and I will use a barrier cream.
  2. I will do pelvic floor exercises and change pads frequently to keep my skin dry. (correct answer)
  3. I will take a laxative daily so I do not have to strain while I wear a pad.
  4. I will use strong soap and scrub the area each day, and I will dry it well.
Explanation: Effective self-care for postpartum stress incontinence focuses on strengthening the pelvic floor and protecting skin from ongoing moisture. The correct statement combines pelvic floor exercises with frequent pad changes, which addresses both the leakage and the mildly reddened skin. Avoiding fluids does not prevent leakage; it risks dehydration and can make urine more concentrated. Taking a laxative daily is unnecessary and may cause diarrhea and irritation; wearing a pad alone does not treat the cause. Using strong soap and scrubbing strips skin oils and worsens the reddened, irritated area; gentle cleansing and patting dry are safer. The key is choosing the statement that directly links muscle strengthening with moisture control.