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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 A

Explanation

Choice A reason: Epoetin alfa is used to treat anemia associated with chronic kidney disease, and iron supplementation is often required to support red blood cell production.

Choice B reason: Sodium intake does not need to be increased with epoetin alfa therapy and should be monitored carefully in clients with chronic kidney disease.

Choice C reason: Potassium levels should be monitored in chronic kidney disease and not necessarily increased, as hyperkalemia can be a concern.

Choice D reason: Protein intake should be managed carefully in chronic kidney disease to avoid excess nitrogen waste, which can be difficult for damaged kidneys to filter.

A. First-voided urine in the morning has a strong odor. B. Urine output of 175 mL in the past 8 hours. C. Urine output of 2,200 mL in the past 24 hours. D. Urine is cloudy after sitting in the urinal for 6 hours.

Correct Answer is B

Explanation

Choice A reason: A strong odor in the first-voided urine can be normal, especially if it's concentrated after a night's sleep.

Choice B reason: An output of 175 mL in 8 hours is concerning, as it indicates oliguria, which is a urine output of less than 400 mL in 24 hours, and can be a sign of worsening renal function.

Choice C reason: An output of 2,200 mL in 24 hours is within normal urine output ranges, which is typically 800 to 2,000 mL per day for an average adult.

Choice D reason: Urine becoming cloudy after sitting for a period is common due to precipitation of salts and proteins at lower temperatures.

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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

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