A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.).

Distended bladder.

Dysuria.

Report of feeling pressure.

Voiding 30 mL frequently.

Tenderness over the symphysis pubis.

Answer and Explanation

Correct Answer : A,C,D,E

Choice A rationale:
A distended bladder is a common sign of urinary retention, which can occur with prostatic hypertrophy. The enlarged prostate can block the flow of urine, causing the bladder to become distended.
Choice B rationale:
Dysuria, or painful urination, is not typically associated with urinary retention. It is more commonly seen in urinary tract infections.
Choice C rationale:
Feeling pressure is a common symptom of urinary retention. The pressure is caused by the buildup of urine in the bladder.
Choice D rationale:
Voiding small amounts frequently can be a sign of urinary retention. The bladder is not able to fully empty, so small amounts of urine are passed frequently.
Choice E rationale:
Tenderness over the symphysis pubis can be a sign of a distended bladder. The bladder is located just behind the symphysis pubis, so distention can cause tenderness in this area.

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Correct Answer is C

Explanation

Choice A rationale:
Determining if the client needs to continue IV therapy is important, but it is not the first action the nurse should take. The nurse should first address the immediate problem, which is the irritated IV site.
Choice B rationale:
Initiating a new IV line in the other extremity is necessary, but not the first action. The nurse should first discontinue the existing IV line to prevent further irritation or infection.
Choice C rationale:
The nurse should first discontinue the existing IV line. This is because the symptoms indicate that the client might have developed phlebitis, an inflammation of the vein, which requires immediate discontinuation of the IV line.
Choice D rationale:
Applying a hot pack to the irritated site can help reduce inflammation and discomfort, but it is not the first action. The nurse should first discontinue the IV line to prevent further complications.

A. Administer pain medication. B. Administer a tetanus booster. C. Clean and dress the wound. D. Administer IV fluids.

Correct Answer is D

Explanation

Choice A rationale:
Administering pain medication is important, but it’s not the first priority. The first priority is to stabilize the client’s condition.
Choice B rationale:
Administering a tetanus booster is necessary for burn patients, but it’s not the first intervention. The first intervention should be to stabilize the client’s condition.
Choice C rationale:
Cleaning and dressing the wound is important, but it’s not the first intervention. The first intervention should be to stabilize the client’s condition.
Choice D rationale:
Administering IV fluids is the first intervention for a burn patient. This is because burns can cause significant fluid loss, leading to dehydration and shock.

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A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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