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.)
Dribbling of urine
Color of the urine
Voiding patern
Proteinuria
Bladder distension
Correct Answer : A,C,E
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: In acute kidney injury (AKI), the blood urea nitrogen (BUN) level is expected to be elevated due to the kidneys' impaired ability to excrete urea, which is a waste product of protein metabolism. Normal BUN levels range from approximately 7 to 20 mg/dL.
Choice B reason: Hypercalcemia is not commonly associated with AKI. Instead, patients with AKI may experience hypocalcemia due to the kidneys' reduced ability to convert vitamin D to its active form, which is necessary for calcium absorption.
Choice C reason: Metabolic alkalosis is not a typical finding in AKI. More commonly, patients with AKI experience metabolic acidosis because the kidneys are unable to excrete acid effectively, leading to an accumulation of acid in the body.
Choice D reason: Hypokalemia is generally not expected in AKI. The condition is more often associated with hyperkalemia, as the impaired kidney function leads to a reduced excretion of potassium, which can accumulate to dangerous levels.
Correct Answer is D
Explanation
Choice A reason: A hemoglobin level of 16 g/dL is within the normal range and does not indicate acute kidney injury.
Choice B reason: A BUN level of 15 mg/dL is also within the normal range and does not suggest acute kidney injury.
Choice C reason: A serum potassium level of 4.5 mEq/L is within the normal range and is not indicative of acute kidney injury.
Choice D reason: A serum creatinine level of 6 mg/dL is significantly elevated and indicates impaired kidney function, which is a hallmark of acute kidney injury.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today