Which assessment technique would provide the most useful data when the nurse is concerned about possible urinary retention?
Auscultate an area six inches below the umbilicus.
Observe the appearance of the patient’s urine.
Palpate the area above the pubic symphysis.
Measure the girth of the patient’s lower abdomen.
The Correct Answer is C
Choice A rationale
Auscultating an area six inches below the umbilicus would not provide the most useful data when assessing for possible urinary retention. Auscultation is typically used to assess bowel sounds and not typically used in the assessment of urinary retention.
Choice B rationale
Observing the appearance of the patient’s urine can provide some information about the patient’s hydration status and kidney function, but it would not be the most useful technique for assessing urinary retention.
Choice C rationale
Palpating the area above the pubic symphysis can provide useful data when assessing for possible urinary retention. If the bladder is distended due to urinary retention, it may be palpable in this area.
Choice D rationale
Measuring the girth of the patient’s lower abdomen is not typically used as a method to assess for urinary retention. While an increase in abdominal girth can occur with urinary retention, it is not the most direct or reliable method for assessment.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
Prompting the nurse to apply povidone to the site is not the correct action in this scenario. Povidone-iodine is an antiseptic used for skin disinfection before and after surgery. It is not typically used in the process of irrigating an intravenous catheter.
Choice B rationale
Directing the nurse to attach the luer-lock tip to the irrigation port is the correct action. A luer-lock syringe is commonly used in medical procedures, including the irrigation of an intravenous catheter. The luer-lock tip provides a secure connection to prevent leaks and ensure that the irrigation solution is delivered directly to the catheter.
Choice C rationale
Sending an unlicensed assistive personnel to gather equipment is not the most appropriate action in this scenario. The new nurse has already gathered the necessary equipment for the procedure.
Choice D rationale
Instructing the nurse to use water with 5% dextrose (D5W) is not the correct action. D5W is a type of intravenous fluid used to correct dehydration and provide calories to the patient. It is not typically used for irrigating an intravenous catheter.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale
Sending wound drainage for culture and sensitivity is a key step in diagnosing and treating VRE. This can help determine the most effective antibiotic treatment20.
Choice B rationale
There is no specific “low bacteria diet” recommended for VRE infections20.
Choice C rationale
Standard precautions, including wearing a mask, are important for preventing the spread of VRE1617181920.
Choice D rationale
Contact precautions, such as wearing gloves and gowns, are recommended for staff and visitors to prevent the spread of VRE1617181920.
Choice E rationale
Monitoring the client’s white blood cell count can help assess the body’s response to the infection and the effectiveness of treatment20.
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