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 D
Explanation
A. High-Fowler:
In the high-Fowler position (sitting upright at 60-90 degrees), gravity pulls the client downward, making it more difficult to reposition them toward the head of the bed.
B. Lateral:
In the lateral position (lying on the side), the client is not aligned for upward movement and would require additional steps to turn them back to a supine position before repositioning.
C. Prone:
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The prone position (lying on the stomach) is not appropriate for repositioning toward the head of the bed, as it makes movement more difficult and increases the risk of injury.
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D. Supine:
This position provides a stable and neutral alignment for the client's body, making it easier to use safe lifting techniques or assistive devices (e.g., draw sheet) to move the client toward the head of the bed.
Correct Answer is B
Explanation
A) While bone marrow does play a role in supporting and protecting bones, its primary function is hematopoiesis.
B) Red bone marrow is responsible for producing various types of blood cells, including white blood cells (leukocytes), red blood cells (erythrocytes), and platelets (thrombocytes).
C) Red bone marrow is primarily involved in hematopoiesis, not calcium storage.
D) This function is more related to the structure and function of joints, ligaments, and muscles, rather than bone marrow.
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