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 C

Explanation

Choice A rationale

Discussing moving to Hawaii does not necessarily indicate a connection to the client’s current condition. It could be a long-term plan or a dream.

Choice B rationale

Being unemotional when talking about needing to rebuild their house could indicate a coping mechanism or emotional detachment. However, without additional context, it’s difficult to definitively associate this behavior with their current condition.

Choice C rationale

Expressing a desire to be in a quieter area of the unit could indicate that the client is experiencing stress, anxiety, or discomfort in their current environment. This behavior is most likely associated with their current condition as it shows a direct response to their surroundings.

Choice D rationale

Requesting sleeping medication for the night could indicate various issues such as insomnia, anxiety, or other sleep-related disorders. However, without more information about the client’s current condition, it’s not possible to make a direct association.

A. Check capillary refill on bilateral upper extremities. B. Administer ondansetron 4 mg IV. C. Inspect the bandage for drainage.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"}}

Explanation

Based on the provided information, here are the interventions the nurse should perform:

Check capillary refill on bilateral upper extremities.- Indicated: This is important to assess the client’s circulation, especially given the coolness of the left arm and the fracture in the left shoulder.
Administer ondansetron 4 mg IV.- Contraindicated: There is no prescription for ondansetron and no indication of nausea or vomiting from the client.
Inspect the bandage for drainage.- Indicated: Given the client’s recent surgery and the presence of swelling and bruising, it’s important to monitor for any signs of infection or complications.

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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

Which client statement or behavior is most likely associated with their current condition?

Correct Answer is C

Explanation

Exhibits Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"}}

Explanation

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