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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Correct Answer is ["A","B","C"]

Explanation

The client’s avoidance of looking at the stoma may indicate anxiety, denial, or emotional distress regarding their condition. This can hinder their ability to engage in self-care and proper management of the ileostomy. The nurse should address these feelings, provide emotional support, and encourage the client to participate in their care.

A lack of interest in learning about stoma care could lead to inadequate management of the ileostomy and increase the risk of complications. It is essential for the nurse to explore the reasons behind this statement, provide education, and emphasize the importance of self-care to promote independence and prevent potential complications.

Redness and open areas around the stoma suggest irritation or possible skin breakdown, which can lead to infection or complications if not treated promptly. The nurse should assess the condition of the skin, implement appropriate skin care measures, and educate the client on maintaining skin integrity around the stoma.

A. Sanguineous B. Serous C. Serosanguineous D. Purulent

Correct Answer is C

Explanation

A. Sanguineous drainage consists mostly of blood and is bright red, indicating active bleeding.

B. Serous drainage is clear or slightly yellowish and watery, often seen in healing wounds.

C. Serosanguineous drainage is a mixture of blood and serous fluid, which is watery with a pink or reddish tinge, common in early wound healing.

D. Purulent drainage is thick and cloudy, indicating infection, usually accompanied by an unpleasant odor.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C"]

Explanation

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following?

Correct Answer is C

Explanation

Which of the following is a common risk factor for developing a urinary tract infection (UTI)?

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