Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

Auscultate an area six inches below the umbilicus.

Palpate the area above the pubic symphysis.

Measure the girth of the client's lower abdomen.

Observe the appearance of the client's urine.

Answer and Explanation

The Correct Answer is B

A. Auscultating below the umbilicus is not effective for assessing urinary retention.

B. Palpating the area above the pubic symphysis allows the nurse to assess for bladder distention, which is a direct indicator of urinary retention.

C. Measuring the girth of the lower abdomen can be useful but is less specific than palpation for assessing bladder fullness.

D. Observing the urine's appearance does not directly assess for 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 B

Explanation

A. Family history of schizophrenia is relevant but not immediately critical.

B. A history of suicide attempts indicates a high risk of self-harm and requires immediate attention in the plan of care.

C. Social anxiety symptoms are important but not as critical as addressing suicide risk.

D. Disorientation needs assessment but is not as urgent as managing suicide risk.

A. Verify that Client B has two units of packed cells available. B. Ask the dietitian to add a banana to Client C's breakfast tray. C. Increase Client A's oxygen to 4 L/minute via nasal cannula. D. Move Client D into an isolation room 24 hours before surgery.

Correct Answer is A

Explanation

A. Client B’s hemoglobin is significantly low, indicating the need for a blood transfusion to improve oxygen-carrying capacity.

B. Client C’s potassium level is within normal limits, so there is no immediate need to add a banana.

C. Client A’s oxygen saturation is acceptable, so increasing the oxygen is unnecessary.

D. Client D’s elevated WBC count may indicate infection, but moving them to isolation before surgery is not required based solely on this finding.

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

Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

The nurse is caring for a client who has a history of experiencing delusions. The client describes singing in a concert in the afternoon for thousands of people. Which action should the nurse take?

A client with generalized anxiety disorder does not want to communicate with friends, smokes 2 to 3 packages of cigarettes a day, and describes difficulty concentrating at work. Which coping strategy should the nurse include in the plan of care?

A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After Initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

When developing a teaching plan for a client with newly diagnosed type 1 diabetes mellitus, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?

Patient Data Exhibits After the obstetrician leaves, the client appears confused and asks the nurse, "How will I know if I have high blood sugar?" Which are the nurse's best responses? Select all that apply.