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 C
Explanation
Choice A reason: Maintaining the client in a left lateral position is not specifically required for peritoneal dialysis. Positioning may vary based on the individual's comfort and specific medical needs.
Choice B reason: While monitoring vital signs is important during any medical procedure, it is not an intervention that directly ensures proper dialysate exchange in peritoneal dialysis.
Choice C reason: Warming the dialysate solution prior to instillation is a standard practice in peritoneal dialysis. It helps to promote patient comfort and more efficient exchange of wastes and fluids.
Choice D reason: Placing the drainage bag above the level of the client's abdomen would impede gravity drainage, which is necessary for proper dialysate exchange. The drainage bag should be placed below the level of the client's abdomen.
.
Correct Answer is B
Explanation
Choice A reason: Specific gravity is typically increased in clients who have hypovolemia, not decreased, due to the concentration of urine as the body atempts to conserve water.
Choice B reason: Creatinine levels are indeed increased in clients who have acute kidney injury, reffecting decreased kidney function and filtration.
Choice C reason: Potassium levels are not necessarily increased in clients who have polyuria. Polyuria can be associated with a variety of conditions and does not directly indicate high potassium levels.
Choice D reason: BUN, or blood urea nitrogen, is typically increased in clients who have dehydration, not decreased, due to the concentration of blood solutes as the body conserves water.
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