PCCSE Exam Questions and Answers

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A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states, "Oh dear, I feel like I have to urinate again!" Which of the following is the most appropriate initial nursing response?
A. Check the collection bag and tubing to verify that the catheter is draining properly.
B. Ask her if she has felt this way before.
C. Instruct her to do Kegel exercises to diminish the urge to void.
D. Assure her that this is most likely the result of bladder spasms.
Answer: A
(A) Although this may be an appropriate response, the initial response would be to assure the patency of the catheter. (B) The most frequent reason for an urge to void with an indwelling catheter is blocked tubing. This response would be the best initial response. (C) Kegel exercises while a retention catheter is in place would not help to prevent a voiding urge and could irritate the urethral sphincter. (D) Though the nurse would want to ascertain whether the client has felt the same urge to void before, the initial response should be to assure the patency of the catheter.

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