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 D
Explanation
Choice A reason: While pain management is important for comfort, it does not directly slow the progression of PKD to ESRD.
Choice B reason: Blood glucose control is important for overall health but is not the most critical factor in slowing the progression of PKD to ESRD.
Choice C reason: Fluid restriction is not typically necessary for PKD unless there is an associated condition that requires it.
Choice D reason: Blood pressure control is crucial in PKD as hypertension can accelerate the progression to ESRD.
Correct Answer is D
Explanation
Choice A reason: Blood-tinged dialysate outflow can occur initially due to the surgical procedure and is not typically a cause for immediate concern unless it persists or is accompanied by other symptoms.
Choice B reason: Dialysate leakage during inflow might indicate a problem with the catheter placement or integrity but is not usually an emergency. It should be monitored and reported if it continues.
Choice C reason: Discomfort during dialysate inflow is common, especially in new patients, as they adjust to the sensation of fluid being infused. It should be reported if the discomfort is severe or persistent.
Choice D reason: Purulent dialysate outflow indicates an infection, such as peritonitis, which is a serious complication
of peritoneal dialysis. This requires immediate atention and intervention by the healthcare provider.
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