HESI RN EXIT 1 PROCTORED EXAM
A client is unable to void following a procedure, so the nurse obtains a prescription to perform a straight catheterization. After inserting the catheter, the nurse serves that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next?
Explanation & Rationale
A. After straight catheterization, assessing for residual urine volume in the bladder helps determine if the bladder has emptied adequately. Palpation of the client's bladder can provide information about residual urine volume. B. Replacing the catheter with an indwelling catheter is not indicated unless there are specific reasons for continuous drainage. C. Allowing the bladder to empty further without assessing for residual distention may lead to incomplete bladder emptying, which can cause urinary retention and discomfort. D. Clamping the catheter for thirty minutes is not appropriate after straight catheterization and may result in urinary retention or discomfort for the client.
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