A nurse is assisting with the plan of care for a client who is immobile and is experiencing urinary retention. The nurse should plan to monitor the client for which of the following?

Bladder outlet obstruction

Protein in the urine

Neurogenic bladder

Urinary tract infection

Answer and Explanation

The Correct Answer is D

A)   Urine retention is a common symptom of bladder outlet obstruction but in this case assessing the patient for a urinary tract infection is the priority.

B)   While proteinuria can indicate kidney dysfunction, it's not directly related to urinary retention.
C)   This refers to bladder dysfunction due to neurological causes and may not be directly related to urinary retention in an immobile client.
D)   Immobility can increase the risk of urinary tract infections Urinary retention can lead to urinary tract infection (UTI) due to bacterial growth in the stagnant urine. The nurse should monitor the client for signs and symptoms of UTI, such as fever, chills, dysuria, hematuria, and foul-smelling urine.

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Correct Answer is D

Explanation

A. High-Fowler:
In the high-Fowler position (sitting upright at 60-90 degrees), gravity pulls the client downward, making it more difficult to reposition them toward the head of the bed.

B. Lateral:
In the lateral position (lying on the side), the client is not aligned for upward movement and would require additional steps to turn them back to a supine position before repositioning.

C. Prone:

The prone position (lying on the stomach) is not appropriate for repositioning toward the head of the bed, as it makes movement more difficult and increases the risk of injury.
D. Supine:
This position provides a stable and neutral alignment for the client's body, making it easier to use safe lifting techniques or assistive devices (e.g., draw sheet) to move the client toward the head of the bed.

A. Minimal assist B. Moderate assist C. No assist D. Maximum assist

Correct Answer is C

Explanation

A. Minimal assist means that the client needs some verbal cues or light touch to perform an activity.
B. Moderate assist means that the client needs physical assistance from one person to perform an activity.
C. The client's ability to rise from a seated position using a cane for support indicates that they require no assistance from the nurse or another person to perform this activity. Therefore, the appropriate activity level assignment is "No assist."
D. Maximum assist means that the client needs physical assistance from two or more people to perform an activity.

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A nurse is assisting with the plan of care for a client who is immobile and is experiencing urinary retention. The nurse should plan to monitor the client for which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to reposition a client towards the head of the bed. In which of the following positions should the nurse place the client before repositioning them to the head of the bed?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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