Question

a client is to be monitored for residual urine every 8 hours. which are appropriate nursing actions for the nurse to complete this task? select all that apply. answer options: 1. obtain a bladder scan before the client voids. 2. have the client void and then perform a bladder scan. 3. if residual urine is less than 100 ml, continue to monitor. 4. reduce oral fluid intake to decrease the amount of residual urine. 5. straight catheterize the client if 100 ml of urine is viewed on the scan. 6. notify the physician immediately if 30 ml of urine is viewed on the scan.

Explanation:

To monitor residual urine, the nurse should have the client void first and then perform a bladder scan to measure the remaining urine. Residual urine less than 100 mL is generally considered acceptable for continued monitoring. Reducing oral fluid intake is not an appropriate action as it can lead to dehydration and other issues. Straight - catheterizing for 100 mL of residual urine is not a standard practice without further assessment. Notifying the physician for 30 mL of residual urine is also not standard. Obtaining a bladder scan before voiding is not the correct procedure for measuring residual urine.

Answer:

1. Have the client void and then perform a bladder scan.
2. If residual urine is less than 100 mL, continue to monitor.