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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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Renal failure is typically associated with abnormal creatinine and BUN levels, which are not

indicated in the given lab values.

Choice B reason: A low-protein diet is not directly indicated by the lab values provided and does not typically result in

collapse after exertion.

Choice C reason: Dehydration is consistent with the client's history of collapsing after playing football on a hot day

and is supported by the elevated sodium level.

Choice D reason: SIADH usually presents with low sodium levels due to dilution, which is not the case here.

A. Postvoid urine residual measurement B. Blood urea nitrogen (BUN) C. Cystourethrogram D. Creatinine E. Kidney, ureter, bladder (KUB) x-ray F. Bladder scan

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

Explanation

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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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is caring for a client who collapsed after playing football on a hot day. After reviewing the admission laboratory findings, the nurse recognizes that these findings are consistent with which of the following conditions?

Correct Answer is C

Explanation

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.)

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

Explanation

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