A nurse is assessing a client who has urinary retention. Which of the following findings should the nurse expect?

Blood in urine

Cloudy urine

Leakage of urine

Dark-colored urine

Answer and Explanation

The Correct Answer is C

A. Blood in the urine (hematuria) is not typically associated with urinary retention but can indicate other conditions such as infection or trauma.

B. Cloudy urine may indicate infection but is not a direct sign of urinary retention.

C. Leakage of urine, or overflow incontinence, occurs when the bladder becomes overly full due to retention and releases small amounts of urine involuntarily.

D. Dark-colored urine typically indicates dehydration, which is not a specific sign of urinary retention.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. The first priority is to protect the wound by covering it with a moist, sterile dressing to prevent further contamination and to stabilize the area until further intervention.

B. Checking the client's vital signs is important, but stabilizing the wound takes precedence.

C. Assessing pain is necessary but not the immediate priority in this situation.

D. A wound culture can be taken later, after covering the wound and ensuring immediate safety.

A. Decreased intestinal peristalsis B. Increased gastric acid production C. Increased muscle tone of the bowel D. Decreased pH of the stomach

Correct Answer is A

Explanation

A. Decreased intestinal peristalsis is a common physiological change in older adults, which can lead to constipation.

B. Older adults typically have decreased gastric acid production, not increased.

C. Muscle tone of the bowel often decreases with age, leading to slower transit times.

D. Stomach pH may increase due to decreased acid production in older adults, not decrease.

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A nurse is assessing a client who has urinary retention. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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