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 D

Explanation

The correct answer is D. The practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients is best assigned to an adult who is one day postoperative for a laparoscopic cholecystectomy. This client’s care involves routine postoperative care and monitoring, which is within the PN’s scope of practice. The other clients have more complex needs that require the higher level of education and skills of an RN.

A. Fresh fruits and vegetables. B. Low fat dairy products. C. Water and herbal teas. D. Iron-rich meats.

Correct Answer is B

Explanation

Choice A rationale

While fresh fruits and vegetables are part of a healthy diet, they are not specifically recommended for the prevention of osteoporosis. They do not contain significant amounts of calcium, which is crucial for bone health.

Choice B rationale

Low fat dairy products are a good source of calcium, which is essential for bone health and the prevention of osteoporosis.

Choice C rationale

While water and herbal teas can contribute to overall hydration, they do not contain significant amounts of calcium or vitamin D, which are crucial for bone health.

Choice D rationale

While iron-rich meats contribute to overall health, they do not contain significant amounts of calcium or vitamin D, which are crucial for bone health.

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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

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