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A nurse is caring for a client in the clinic who has a distended bladder with discomfort over the area and a sense of fullness. Which of the following tests should the nurse expect the health care provider to order to determine if the client has urinary retention? (Select all that apply.)

Postvoid urine residual measurement

Blood urea nitrogen (BUN)

Cystourethrogram

Creatinine

Kidney, ureter, bladder (KUB) x-ray

Bladder scan

Answer and Explanation

Correct Answer : A,E,F

Choice A reason: Postvoid urine residual measurement is a direct method to assess for urinary retention.

Choice B reason: Blood urea nitrogen (BUN) levels may indicate kidney function but not specifically urinary retention.

Choice C reason: A cystourethrogram is used to visualize the bladder and urethra, which may not be the first choice for assessing urinary retention.

Choice D reason: Creatinine levels indicate kidney function but not urinary retention.

Choice E reason: A kidney, ureter, bladder (KUB) x-ray can show the size of the bladder and may indicate retention.

Choice F reason: A bladder scan is a non-invasive way to measure the amount of urine in the bladder and assess for

retention.

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Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Dribbling of urine can indicate urinary retention, as it may suggest that the bladder is not emptying

completely during voiding.

Choice B reason: While the color of the urine can provide information about hydration status and other health issues, it is not a direct indicator of urinary retention.

Choice C reason: The voiding patern is an important assessment for urinary retention. Infrequent voiding or small amounts despite a full bladder can be signs of this condition.

Choice D reason: Proteinuria is not typically used as an assessment for urinary retention. It can indicate kidney damage or disease but does not directly relate to the bladder's ability to empty.

Choice E reason: Bladder distension can be observed and palpated in cases of urinary retention, as the bladder may become enlarged due to the accumulation of urine.

A. A raised red rash around the fistula site B. Coldness and numbness distal to the fistula site C. Pain in the right arm proximal to the fistula site D. Foul-smelling drainage from the fistula site

Correct Answer is B

Explanation

Choice A reason: A raised red rash is not typically indicative of venous insufficiency but could suggest an allergic reaction or infection.

Choice B reason: Coldness and numbness distal to the fistula site can indicate poor blood flow, which is a symptom of venous insufficiency.

Choice C reason: Pain proximal to the fistula site can be a sign of venous hypertension and insufficiency, as it may

indicate increased pressure in the veins.

Choice D reason: Foul-smelling drainage is not a typical sign of venous insufficiency but may indicate an infection.

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A nurse is caring for a client in the clinic who has a distended bladder with discomfort over the area and a sense of fullness. Which of the following tests should the nurse expect the health care provider to order to determine if the client has urinary retention? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for older adult clients at a long-term care facility. Which of the following assessments should the nurse consider when monitoring clients for urinary retention? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as possible indications of venous insufficiency?

Correct Answer is B

Explanation

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