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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Correct Answer is C

Explanation

Rationale:

A. Drinking plenty of water helps to flush bacteria from the urinary tract, reducing the risk of a UTI.

B. Good personal hygiene reduces the risk of UTIs by preventing bacterial contamination.

C. Urinary catheters provide a direct pathway for bacteria to enter the bladder, increasing the risk of UTIs.

D. Frequent handwashing is a preventive measure but not directly related to the development of UTIs.

A. Keep the client's skin dry with powder. B. Implement turning schedule every 4 hr. C. Massage over erythematous bony prominences. D. Use pillows to keep heels off the bed surface. E. Minimize skin exposure to moisture.

Correct Answer is ["D","E"]

Explanation

A. Using powder can cause skin irritation and dryness and is not recommended for preventing skin breakdown.

B. Clients should be repositioned at least every 2 hours, not every 4 hours, to prevent pressure ulcers.

C. Massaging over erythematous areas can damage fragile tissue and increase the risk of skin breakdown.

D. Using pillows to keep heels off the bed surface helps relieve pressure on bony prominences, reducing the risk of pressure ulcers.

E. Minimizing skin exposure to moisture prevents maceration and skin breakdown, especially in incontinent clients.

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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

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Explanation

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Explanation

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