A nurse is assessing a client who has urinary retention. Which of the following findings should the nurse expect?

Blood in urine

Cloudy urine

Leakage of urine

Dark-colored urine

Answer and Explanation

The Correct Answer is C

A. Blood in the urine (hematuria) is not typically associated with urinary retention but can indicate other conditions such as infection or trauma.

B. Cloudy urine may indicate infection but is not a direct sign of urinary retention.

C. Leakage of urine, or overflow incontinence, occurs when the bladder becomes overly full due to retention and releases small amounts of urine involuntarily.

D. Dark-colored urine typically indicates dehydration, which is not a specific sign of urinary retention.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. The head of the bed should be elevated no more than 30° to prevent shearing forces on the skin.

B. Baby powder can cause dryness and irritation rather than protecting the skin.

C. Lifting rather than pulling reduces the risk of friction and shearing forces, which can lead to skin breakdown and pressure ulcers.

D. Massaging reddened skin over bony prominences can damage already compromised tissue and increase the risk of pressure ulcers.

A. Decreased intestinal peristalsis B. Increased gastric acid production C. Increased muscle tone of the bowel D. Decreased pH of the stomach

Correct Answer is A

Explanation

A. Decreased intestinal peristalsis is a common physiological change in older adults, which can lead to constipation.

B. Older adults typically have decreased gastric acid production, not increased.

C. Muscle tone of the bowel often decreases with age, leading to slower transit times.

D. Stomach pH may increase due to decreased acid production in older adults, not decrease.

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A nurse is assessing a client who has urinary retention. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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