A nurse is reviewing urinary laboratory results. Which findings should prompt the nurse to follow up?

Choice A rationale

Measuring the bladder before the patient voids would not provide an accurate measurement of postvoid residual, which is the amount of urine left in the bladder after voiding.

Choice B rationale

The position of the head of the bed does not directly impact the measurement of postvoid residual. However, the patient should be in a comfortable position during the procedure.

Choice C rationale

Similar to Choice B, the position of the head of the bed does not directly impact the measurement of postvoid residual.

Choice D rationale

Measuring the bladder within 15 minutes after the patient voids allows for an accurate measurement of postvoid residual, which can help assess bladder function.

The client is at greatest risk for developing a Pressure ulcer due to Limited mobility.

The client’s limited mobility and the need for assistance to turn and transfer out of bed increases the risk of pressure ulcers. Pressure ulcers, also known as bedsores, are injuries to the skin and underlying tissue resulting from prolonged pressure on the skin. They most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips, and tailbone. People most at risk of pressure ulcers are those with a medical condition that limits their ability to change positions or those who spend most of their time in a bed or chair.