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: The pulmonary artery is the large blood vessel that carries deoxygenated blood from the right ventricle to the lungs for gas exchange. It is the only artery that carries deoxygenated blood in the body.
Choice B reason: The pulmonary veins are the blood vessels that carry oxygenated blood from the lungs to the left atrium. They are the only veins that carry oxygenated blood in the body.
Choice C reason: The left ventricle is the chamber of the heart that pumps oxygenated blood to the rest of the body through the aorta. It does not directly connect to the lungs.
Choice D reason: The left atrium is the chamber of the heart that receives oxygenated blood from the pulmonary veins. It does not directly connect to the right ventricle.
Correct Answer is C
Explanation
Choice A reason: The nurse applies the sterile drape prior to cleansing the perineal area. This is a correct action by the nurse, as it helps to prevent contamination of the catheter insertion site and maintain a sterile field.
Choice B reason: The nurse coats the indwelling urinary catheter with lubricant. This is a correct action by the nurse, as it helps to ease the insertion of the catheter and reduce the risk of trauma or infection.
Choice C reason: The nurse separates the client's labia with her dominant hand. This is an incorrect action by the nurse, as it violates the principle of sterile technique. The nurse should use her non-dominant hand to separate the labia and expose the urethral meatus, and use her dominant hand to hold the catheter. The non-dominant hand should not touch anything else after separating the labia, as it is considered contaminated.
Choice D reason: The nurse provides perineal care prior to inserting the urinary catheter. This is a correct action by the nurse, as it helps to reduce the bacterial load and prevent infection. The nurse should use soap and water to cleanse the perineal area from front to back, and use a new washcloth for each stroke.
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