A nurse is assisting with the plan of care for a client who is immobile and is experiencing urinary retention. The nurse should plan to monitor the client for which of the following?
Bladder outlet obstruction
Protein in the urine
Neurogenic bladder
Urinary tract infection
The Correct Answer is D
A) Urine retention is a common symptom of bladder outlet obstruction but in this case assessing the patient for a urinary tract infection is the priority.
B) While proteinuria can indicate kidney dysfunction, it's not directly related to urinary retention.
C) This refers to bladder dysfunction due to neurological causes and may not be directly related to urinary retention in an immobile client.
D) Immobility can increase the risk of urinary tract infections Urinary retention can lead to urinary tract infection (UTI) due to bacterial growth in the stagnant urine. The nurse should monitor the client for signs and symptoms of UTI, such as fever, chills, dysuria, hematuria, and foul-smelling urine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Removing contaminated clothing is the first step in chemical exposure situations, since it reduces further absorption of the chemical.
B) Maintaining a safe distance from the client helps prevent potential exposure to the unknown chemical but removing contaminated clothes is the priority.
C) This step can be taken later for proper disposal but is not the immediate priority.Showering is an essential step after clothing removal to decontaminate the skin, but scrubbing should be avoided as it may cause further chemical absorption or skin irritation. Gentle rinsing with water is preferred.
D) While decontamination is important, it should be done by trained personnel using appropriate protocols and protective equipment.
Correct Answer is B
Explanation
A) Orthostatic hypotension primarily affects blood pressure regulation and is not directly related to the risk of pulmonary emboli.
B) Orthostatic hypotension can cause dizziness and fainting upon standing, increasing the risk of falls.
C) Orthostatic hypotension is typically indicated by a decrease in systolic blood pressure of 20 mm Hg or more.
D) Orthostatic hypotension is primarily diagnosed based on changes in systolic blood pressure, not diastolic blood pressure.
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