A nurse is collecting data on a client who has urinary retention. Which of the following findings should the nurse expect?
Leakage of urine
Dark-colored urine
Cloudy urine
Blood in urine
The Correct Answer is A
Choice A reason: Leakage of urine is a sign of urinary retention, as it indicates that the bladder is overdistended and unable to empty completely. The urine may leak around the urethra or through a catheter.
Choice B reason: Dark-colored urine is not a sign of urinary retention. It can be caused by dehydration, certain foods or medications, or liver or kidney problems.
Choice C reason: Cloudy urine is not a sign of urinary retention. It can be caused by infection, inflammation, or stones in the urinary tract.
Choice D reason: Blood in urine is not a sign of urinary retention. It can be caused by trauma, infection, cancer, or coagulation disorders in the urinary tract.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Muscle twitching is a sign of central nervous system oxygen toxicity, which can occur when breathing high concentrations of oxygen under pressure. It can also cause seizures, confusion, and loss of consciousness.
Choice B reason: Facial flushing is not a symptom of oxygen toxicity. It can be caused by other conditions such as fever, allergic reactions, or alcohol consumption.
Choice C reason: Periorbital edema is not a symptom of oxygen toxicity. It can be caused by other conditions such as kidney disease, heart failure, or allergies.
Choice D reason: Metallic taste in mouth is not a symptom of oxygen toxicity. It can be caused by other conditions such as medication side effects, dental problems, or infections.
Correct Answer is A,B,C,D
Explanation
Choice A reason: Confirming the client's identity by checking their wristband is the first step to ensure that the right client receives the right treatment.
Choice B reason: Providing for the client's privacy by closing the curtains is the second step to respect the client's dignity and comfort.
Choice C reason: Assisting the client into the Sims' position is the third step to facilitate the insertion of the enema tubing and the flow of the solution. The Sims' position is a side-lying position with the upper leg flexed and the lower leg straight.
Choice D reason: Inserting the tip of the enema tubing into the client's rectum is the fourth and final step to administer the enema. The nurse should lubricate the tip of the tubing, gently insert it about 3 to 4 inches into the rectum, and release the clamp to allow the solution to flow. The nurse should monitor the client for any signs of discomfort or cramping and adjust the flow rate accordingly.
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