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.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A rationale

A lung biopsy is an invasive procedure that is typically performed to diagnose conditions such as lung cancer or interstitial lung disease. It is not the first-line test for evaluating increased shortness of breath in a client with COPD56.

Choice B rationale

Spirometry is a common, non-invasive test used to assess lung function and is particularly useful in conditions like COPD. It measures the volume and speed of air a person can inhale and exhale, which can help in assessing the severity of COPD56.

Choice C rationale

Antibody testing is typically used to diagnose conditions related to the immune system, such as allergies or autoimmune diseases. It is not typically used to evaluate shortness of breath in a client with COPD56.

Choice D rationale

A sweat test is used to diagnose cystic fibrosis by measuring the amount of salt in a person’s sweat. It is not used to evaluate shortness of breath in a client with COPD56.

Correct Answer is ["1.32"]

Explanation

Step 1 is to convert the patient’s weight from pounds to kilograms. There are approximately 2.2046 pounds in 1 kilogram. So, the patient’s weight in kilograms is 132 lb ÷ 2.2046 = 59.87 kg.

Step 2 is to calculate the total dose of lorazepam the patient should receive. The prescribed dose is 44 mcg/kg. So, the total dose in micrograms is 44 mcg/kg × 59.87 kg = 2634.28 mcg.

Step 3 is to convert the total dose from micrograms to milligrams. There are 1000 micrograms in 1 milligram. So, the total dose in milligrams is 2634.28 mcg ÷ 1000 = 2.63428 mg.

Step 4 is to calculate the volume of lorazepam solution to administer. The concentration of the solution is 2 mg/mL. So, the volume in milliliters is 2.63428 mg ÷ 2 mg/mL = 1.31714 mL. Therefore, the nurse should administer approximately 1.32 mL of the lorazepam solution, rounding to the nearest hundredth as required.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath with activity.Which test should the nurse schedule the client for evaluation of the symptoms?

Correct Answer is B

Explanation

A patient weighing 132 lb is prescribed lorazepam 44 mcg/kg IV to be administered 20 minutes before a scheduled procedure. The medication is available in a 2 mg/mL vial. How many mL should the nurse administer? Round off to 2 d.p. (This is a medical math nd does not require options.)

Correct Answer is ["1.32"]

Explanation

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