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) This is a medication error, but since it was intercepted before harm occurred, it does not qualify as a sentinel event.
B) While a fall resulting in a fracture is serious, it is not classified as a sentinel event unless the fall results in death, permanent harm, or significant temporary harm.
C) This is a near-miss medication error, which is important to report and investigate but does not meet the criteria for a sentinel event.
D) A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Death from sepsis following surgery would qualify as a sentinel event.
Correct Answer is C
Explanation
A. Minimal assist means that the client needs some verbal cues or light touch to perform an activity.
B. Moderate assist means that the client needs physical assistance from one person to perform an activity.
C. The client's ability to rise from a seated position using a cane for support indicates that they require no assistance from the nurse or another person to perform this activity. Therefore, the appropriate activity level assignment is "No assist."
D. Maximum assist means that the client needs physical assistance from two or more people to perform an activity.
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