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 ["A","B","C","G"]

Explanation

A. Rise slowly when getting up: Finasteride and tamsulosin can cause orthostatic hypotension, making it important for the client to change positions slowly to prevent dizziness and falls.

B. Take medication in the morning: Tamsulosin is typically taken once daily, 30 minutes after the same meal each day, often recommended in the morning to align with the daily routine and reduce the likelihood of missing doses.

C. Erectile dysfunction is common with the prescribed medication: Finasteride may cause sexual side effects such as erectile dysfunction, decreased libido, and ejaculation disorders. It is important to inform the client of these potential side effects.

D. Medication may cause the heart to race: This is not a common side effect of finasteride or tamsulosin. Tamsulosin can cause hypotension, but it does not typically cause tachycardia.

E. Ibuprofen should be taken 2 hours before taking medication: There is no specific interaction that requires timing ibuprofen around these medications.

F. Symptoms should be resolved within 1 week: Improvement in symptoms of benign prostatic hyperplasia (BPH) with medications like finasteride and tamsulosin typically takes several weeks to months, not just one week.

G. Ensure cane is used when ambulating: Given the client's use of a cane and the potential for orthostatic hypotension, it is crucial to reinforce the use of the cane to prevent falls and ensure safe ambulation.

A. Increased fatigue. B. Watery diarrhea. C. Nausea and headache. D. Yellow-tinged sputum.

Correct Answer is B

Explanation

A. Increased fatigue is a common side effect of many medications and illnesses but is not as immediately concerning.

B. Watery diarrhea can indicate a serious side effect such as Clostridium difficile-associated diarrhea, which requires prompt medical attention.

C. Nausea and headache are common side effects but are generally not urgent.

D. Yellow-tinged sputum can indicate infection but is not as critical as the potential for a serious gastrointestinal issue.

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

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