Try Naxlex NCLEX-RN (Free-Trial)

When caring for older adult clients at a long-term care facility, which of the following assessments should the nurse prioritize when evaluating for the risk and presence of urinary retention? (Select all that apply.)

Observing for changes in urinary patterns, such as a sudden decrease in urinary output or frequent, small amounts of voiding.

Assessing for reports of urinary hesitancy, dribbling of urine, straining, or a sensation of incomplete bladder emptying during urination.

Encouraging the client to drink large amounts of fluid in a short period to stimulate bladder emptying.

Applying pressure over the lower abdomen to force urine out of the bladder.

Evaluating for palpable bladder distention after voiding to assess incomplete bladder emptying.

Answer and Explanation

Correct Answer : A,B,E

A. Observing for changes in urinary patterns, such as a sudden decrease in urinary output or frequent, small amounts of voiding. This can indicate urinary retention, as frequent, small voids may suggest incomplete emptying of the bladder.

B. Assessing for reports of urinary hesitancy, dribbling of urine, straining, or a sensation of incomplete bladder emptying during urination. These symptoms are common in urinary retention, indicating that the client is having difficulty fully emptying the bladder.

C. Encouraging the client to drink large amounts of fluid in a short period to stimulate bladder emptying: This is incorrect, as overhydration can worsen urinary retention, especially in clients with an impaired ability to empty their bladder.

D. Applying pressure over the lower abdomen to force urine out of the bladder: This is incorrect and can cause harm, as it may increase the risk of bladder injury.

E. Evaluating for palpable bladder distention after voiding to assess incomplete bladder emptying.
A distended bladder after voiding suggests incomplete emptying and potential urinary retention.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Provide emotional support: While emotional support is important, addressing physical health issues like fluid and electrolyte balance takes priority during an acute exacerbation.

B. Review stress factors that can cause disease exacerbation: This is important for long-term management but is not the immediate priority during an acute exacerbation.

C. Promote physical mobility: Physical mobility may be limited due to pain or weakness, but it is not the primary concern during an exacerbation.

D. Evaluate fluid and electrolyte levels. Fluid and electrolyte imbalances are common during an exacerbation of ulcerative colitis due to diarrhea and bleeding, making it the top priority to assess and manage to prevent complications such as dehydration or hypovolemia.

A. "Eating contaminated food or water from an infected source can cause you to become infected with hepatitis C B. "Coming into contact with infected blood, such as from that of a dirty needle, can cause you to become infected with hepatitis C. C. "Coming into contact with an infected person's bodily fluids, such as saliva, can cause you to become infected with hepatitis C. D. "Consuming a large amount of alcohol at one time can cause you to become infected with hepatitis C.”

Correct Answer is B

Explanation

A. "Eating contaminated food or water from an infected source can cause you to become infected with hepatitis C." This applies to hepatitis A, not hepatitis C. Hepatitis A is transmitted through the fecal-oral route, whereas hepatitis C is bloodborne.

B. "Coming into contact with infected blood, such as from that of a dirty needle, can cause you to become infected with hepatitis C." Hepatitis C is primarily spread through blood-to-blood contact, most commonly through sharing needles, blood transfusions before widespread blood screening, or needle-stick injuries.

C. "Coming into contact with an infected person's bodily fluids, such as saliva, can cause you to become infected with hepatitis C." Hepatitis C is not commonly spread through casual contact or saliva. The risk of transmission through bodily fluids other than blood is extremely low.

D. "Consuming a large amount of alcohol at one time can cause you to become infected with hepatitis C." Alcohol does not cause hepatitis C, though it can worsen liver damage in individuals already infected with the virus.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

When caring for older adult clients at a long-term care facility, which of the following assessments should the nurse prioritize when evaluating for the risk and presence of urinary retention? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis. The nurse should recognize that which of the following actions is the priority?

Correct Answer is D

Explanation

A nurse is reinforcing teaching to a client who has been newly diagnosed with hepatitis C. The client asks how they could have contracted the virus. Which of the following nurse responses best explains how the client may have become infected with hepatitis C?

Correct Answer is B

Explanation

A male patient is being discharged after hospitalization for a bleeding peptic ulcer. The nurse is providing discharge teaching on how to monitor for signs of recurrent bleeding. Which of the following statements by the patient indicates a need for further teaching?

A patient with a history of ulcerative colitis presents to the emergency department with severe abdominal pain, frequent bloody diarrhea, and signs of dehydration. Which medication should the nurse anticipate administering during this exacerbation of ulcerative colitis?

A patient with suspected appendicitis is being prepared for surgery. Which of the following preoperative interventions should the nurse prioritize?

A nurse is assessing an older adult client who has a urinary tract infection (UTI). Which of the following findings should the nurse identify as unique for this age group?

A female patient presents with epigastric pain and is being evaluated for peptic ulcer disease (PUD). Upon reviewing her history, which of the following risk factors would be most indicative of increasing his likelihood of developing PUD?