A client had an inguinal hernia repair 8 hours ago. The prescriber's order reads: 'Bladder scan if unable to void or if voiding small amounts; straight catheterize if the scanned volume is over 400 mL.' With help to the bathroom the client passed 50 mL of urine and reports lower abdominal pressure. The nurse feels a firm swelling above the symphysis pubis. What should the nurse do first?
Insert a straight catheter as ordered
Measure the bladder volume with a portable bladder scanner
Encourage the client to drink more fluids over the next hour
Record the voided amount and reassess the client in 2 hours
Show the answer and explanation
Answer: B. Measure the bladder volume with a portable bladder scanner
Topic: urinary retention
Small voidings with a palpable bladder suggest retention with overflow. A bladder scan is a noninvasive assessment that confirms how much urine is retained, so that catheterization, with its infection risk, is done only when it is needed.
Why the others are wrong
A – The order makes catheterization conditional on a scanned volume over 400 mL; inserting a catheter before the scan skips the required assessment and may expose the client to an unnecessary invasive procedure.
C – More fluid adds to the volume in a bladder that is already not emptying.
D – Waiting allows the bladder to overdistend, which injures the detrusor muscle and promotes infection.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
2Question
The nurse is caring for a client with an indwelling urinary catheter. Which actions help prevent a catheter-associated urinary tract infection?
Select all that apply.
Keep the drainage bag below the level of the bladder and off the floor
Clean the urinary meatus with an antiseptic solution twice a day
Secure the catheter to the client with a securement device
Disconnect the catheter from the drainage tubing to collect a urine specimen
Review each day with the health care provider whether the catheter is still needed
Empty the bag into a clean container used only for this client, without letting the spout touch it
Show the answers and explanation
Answers: A, C, E and F.
A – Keep the drainage bag below the level of the bladder and off the floor
C – Secure the catheter to the client with a securement device
E – Review each day with the health care provider whether the catheter is still needed
F – Empty the bag into a clean container used only for this client, without letting the spout touch it
Topic: CAUTI prevention
Infection is prevented by unobstructed downhill drainage, a closed system, a secured catheter that does not move in the urethra, clean emptying technique and removing the catheter as soon as it is no longer indicated. Duration of catheterization is the most important risk factor.
Why the others are wrong
B – Routine hygiene with soap and water is sufficient; cleaning the meatus with antiseptics does not lower infection rates and is not recommended.
D – Opening the closed system admits organisms; a specimen is taken from the sampling port after it is disinfected.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
3Question
An older client who takes an opioid for chronic pain has had no formed bowel movement for 5 days. The client now has a distended abdomen, a feeling of rectal fullness and continuous seepage of small amounts of liquid stool. What should the nurse do first?
Request an order for an antidiarrheal medication
Send a stool specimen for culture
Assess the rectum for a fecal impaction according to agency policy
Give a bulk-forming fiber supplement with a glass of water
Show the answer and explanation
Answer: C. Assess the rectum for a fecal impaction according to agency policy
Topic: constipation and fecal impaction
Liquid stool leaking around a hard mass after days without a bowel movement is the typical sign of fecal impaction, especially in a client taking opioids. The nurse confirms the impaction by assessment before any treatment is chosen.
Why the others are wrong
A – An antidiarrheal slows the bowel further and worsens an impaction; the seepage is not true diarrhea.
B – The history points to obstruction by stool, not infection; a culture delays the needed assessment.
D – Bulk-forming agents add mass behind an obstruction and can make an impaction worse.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
4Question
The nurse assesses a client on the first day after creation of a sigmoid colostomy. Which finding needs follow-up?
The stoma is beefy red and moist
The stoma is slightly swollen
A small amount of blood appears when the stoma is cleaned
The stoma is dusky purple
Show the answer and explanation
Answer: D. The stoma is dusky purple
Topic: stoma assessment
A healthy stoma is red or pink and moist because it is well-perfused bowel mucosa. A dusky, purple, brown or black stoma indicates impaired blood supply and possible necrosis and must be reported at once.
Why the others are wrong
A – A beefy red, moist stoma is the expected appearance.
B – Mild edema is expected for the first weeks after surgery and subsides gradually.
C – The mucosa is very vascular, so slight bleeding on cleaning is expected.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
5Question
A 58-year-old client reports leaking a small amount of urine whenever she coughs, laughs or lifts something heavy. She has no urgency, and a bladder scan after voiding shows no retained urine. Which intervention should the nurse teach?
Pelvic floor muscle exercises performed several times each day
Intermittent self-catheterization every 4 to 6 hours
Limiting total fluid intake to less than 1 liter a day
Pressing down over the bladder with the hands at the end of each void
Show the answer and explanation
Answer: A. Pelvic floor muscle exercises performed several times each day
Topic: types of urinary incontinence
Leakage with a rise in abdominal pressure and no urgency or retention is stress incontinence, caused by weak pelvic floor and urethral support. Pelvic floor muscle exercises strengthen that support and are the first-line treatment.
Why the others are wrong
B – Intermittent catheterization treats retention and overflow incontinence; this client empties her bladder completely.
C – Severe fluid restriction concentrates the urine, irritates the bladder and risks dehydration and infection.
D – Manual pressure over the bladder is a technique for a bladder that does not empty; it would increase leakage here.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
6Question
The nurse is planning a bowel retraining program for a client recovering from a stroke who has frequent bowel incontinence. Which interventions should the nurse include?
Select all that apply.
Assist the client to the toilet at the same time each day, about 30 minutes after a meal
Provide adequate fluids and a diet with enough fiber
Limit the client's fluid intake so that stools become firmer and less frequent
Have the client sit upright on a toilet or commode, with privacy
Ask the client to hold back the urge to defecate until the scheduled time
Show the answers and explanation
Answers: A, B and D.
A – Assist the client to the toilet at the same time each day, about 30 minutes after a meal
B – Provide adequate fluids and a diet with enough fiber
D – Have the client sit upright on a toilet or commode, with privacy
Topic: bowel retraining
Bowel retraining builds a regular habit by using the gastrocolic reflex after meals, a consistent time, soft formed stool from fluids and fiber, and an upright sitting position that lets gravity and abdominal muscles help.
Why the others are wrong
C – Restricting fluids produces hard stool and constipation rather than a predictable pattern; a bowel program needs adequate fluid and fiber.
E – Ignoring the urge weakens the defecation reflex and leads to constipation; the client is helped to the toilet whenever the urge occurs.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
7Question
An 80-year-old resident with arthritis who uses a walker is cognitively intact and empties the bladder completely, but is often wet because she cannot reach the toilet in time. Which plan best fits this type of incontinence?
Teach pelvic floor exercises as the main intervention
Remove barriers and provide a bedside commode with prompted or scheduled toileting
Request an anticholinergic medication
Insert an indwelling urinary catheter
Show the answer and explanation
Answer: B. Remove barriers and provide a bedside commode with prompted or scheduled toileting
Topic: Types of urinary incontinence
Incontinence caused by limited mobility, cognition or environmental barriers is functional incontinence. Management addresses the barriers: easy access to toileting, simple-to-manage clothing and scheduled toileting.
Why the others are wrong
A – Pelvic floor exercises treat sphincter weakness, not an access problem.
C – Anticholinergics are a Beers concern and do not help her reach the toilet.
D – A catheter for incontinence alone adds infection risk and is not indicated.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
8Question
Four hours after a vaginal birth, a client's fundus is firm but is 3 cm above the umbilicus and displaced to the right. Lochia is moderate. She has not voided since the birth. Which action should the nurse take first?
Ask the provider for an oxytocic medication
Insert an indwelling urinary catheter
Record the findings as expected for 4 hours after birth
Help the client to the bathroom to try to void
Show the answer and explanation
Answer: D. Help the client to the bathroom to try to void
Topic: postpartum bladder distension
A full bladder lifts the uterus and pushes it to one side, and can prevent it from contracting well. Emptying the bladder is the first step; the least invasive way is to help the client void, with catheterization only if she cannot.
Why the others are wrong
A – The uterus is firm; the problem is displacement by the bladder, not poor tone.
B – Catheterization carries a risk of infection and is used only if she cannot void.
C – A fundus above the umbilicus and off the midline is not expected and, left alone, can lead to atony and bleeding.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
9Question
A nurse reviews the results of an adult male client. Which result is most suggestive of reduced kidney function?
Serum creatinine of 0.9 mg/dL and a normal urinalysis result
Estimated glomerular filtration rate of 48 mL/min/1.73 m2
Blood urea nitrogen of 14 mg/dL
Serum potassium of 4.2 mEq/L
Show the answer and explanation
Answer: B. Estimated glomerular filtration rate of 48 mL/min/1.73 m2
Topic: laboratory markers of kidney function
A filtration rate below 60 mL/min/1.73 m2 indicates reduced kidney function. The other values are within the usual ranges for an adult male.
Why the others are wrong
A – Within the usual range for an adult male.
C – A blood urea nitrogen level of 14 mg/dL falls within the normal range for an adult male and does not indicate reduced kidney function.
D – A serum potassium level of 4.2 mEq/L is within the normal range and does not specifically suggest reduced kidney function.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
10Question
A 70-year-old man with benign prostatic hyperplasia voids, and a bladder scan three minutes later shows 280 mL. What should the nurse do?
Document a normal postvoid volume and encourage fluids
Rescan after an hour to see if the volume has fallen
Report incomplete bladder emptying and anticipate an order for catheterization
Restrict fluids for the rest of the shift
Show the answer and explanation
Answer: C. Report incomplete bladder emptying and anticipate an order for catheterization
Topic: interpreting a postvoid residual
A postvoid residual is measured right after voiding. A large residual such as 280 mL indicates retention, and the provider is notified because catheterization may be needed to protect the bladder and kidneys from back pressure.
Why the others are wrong
A – A residual of this size is not normal.
B – Delaying lets the bladder stay overdistended and does not change what the first scan showed.
D – Restricting fluids does not treat retention and may cause dehydration.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
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