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.

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Correct Answer is C

Explanation

A. Increased urination due to IV fluids is common and not immediately concerning.

B. Comfort with an elevated head of bed is typical postoperatively.

C. A tight dressing could indicate swelling or a potential complication such as hematoma, which can compromise the airway and requires immediate assessment.

D. Dizziness upon standing is common and not as urgent as potential airway compromise.

A. Morphine. B. Aspirin. C. Heparin. D. Nitroglycerin.

Correct Answer is D

Explanation

A. Morphine is used for pain management and is not contraindicated with sildenafil.

B. Aspirin is used for its antiplatelet effect and is not contraindicated with sildenafil.

C. Heparin is used as an anticoagulant and is not contraindicated with sildenafil.

D. Nitroglycerin is contraindicated with sildenafil because the combination can cause severe hypotension.

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