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 B
Explanation
Choice A reason: Muscle spasms are not typically associated with aluminum hydroxide use.
Choice B reason: Constipation is a common adverse effect of aluminum hydroxide, especially when used as a
phosphate binder in clients with renal failure.
Choice C reason: Headaches are not commonly reported as an adverse effect of aluminum hydroxide.
Choice D reason: A metallic taste is not a common adverse effect associated with aluminum hydroxide.
Correct Answer is ["B","D","E"]
Explanation
Choice A reason: Driving restrictions are not typically necessary for clients on hemodialysis unless there are other underlying conditions affecting their ability to drive safely.
Choice B reason: Clients on hemodialysis need to restrict foods high in potassium, sodium, and phosphorus to manage their electrolyte levels and prevent complications.
Choice C reason: Airplane travel is not generally restricted for hemodialysis clients, but they may need to arrange for dialysis at their destination.
Choice D reason: Time constraints are a significant factor as hemodialysis requires several hours per session, multiple times a week.
Choice E reason: Fluid intake often needs to be restricted in clients on hemodialysis to prevent fluid overload, as the kidneys are not able to remove excess fluid effectively.
Choice F reason: Limiting social activities is not a necessary restriction unless it is related to the client's overall health status.
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