A nurse is caring for a group of clients on a medical surgical unit.
Which of the following clients is at risk for urinary retention?
Clients who had recent surgery with general anesthesia.
Clients who have liver failure and are at risk for acute kidney injury.
The client who reported eating a diet high in calcium oxalate.
Clients who have recent staphylococcal infection and are at risk for glomerulonephritis.
The Correct Answer is A
Choice A rationale
General anesthesia and the use of certain medications during surgery, such as opioids, can significantly impair detrusor muscle contraction and/or interfere with the sensation of bladder fullness, leading to temporary urinary retention. Surgical manipulation in the pelvic area can also contribute to temporary nerve dysfunction, which subsequently impairs the normal voiding reflex.
Choice B rationale
Liver failure, while causing numerous systemic effects, primarily affects clotting factors, drug metabolism, and albumin synthesis. It does not directly cause an increased risk of acute urinary retention through a known physiological mechanism; the risk of acute kidney injury from hepatorenal syndrome is an entirely separate and distinct complication.
Choice C rationale
A diet high in calcium oxalate is a risk factor for the formation of calcium oxalate kidney stones (nephrolithiasis). While kidney stones can potentially cause obstruction leading to post-renal acute kidney injury or urinary retention, the diet itself is not the primary direct risk factor for retention compared to immediate post-operative effects.
Choice D rationale
Glomerulonephritis is an inflammatory disease of the kidney glomeruli, often following an infection like streptococcal pharyngitis (not staphylococcal). This primarily leads to hematuria, proteinuria, and decreased glomerular filtration rate, not specifically an increased risk for acute urinary retention, which is a lower urinary tract issue. —.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale
Testing the balloon on an indwelling urinary catheter before insertion is a crucial safety step in the preparation process. This action ensures that the balloon, which is inflated with sterile water after insertion to anchor the catheter in the bladder, does not have a leak and will properly inflate. A non-functional balloon requires catheter replacement before the sterile procedure continues.
Choice A rationale
A water-soluble, sterile lubricant is necessary for catheter insertion to minimize friction and tissue trauma to the urethra. Oil-based lubricants are contraindicated because they can damage the latex or silicone material of the catheter and may be difficult to remove, potentially increasing the risk of infection.
Choice C rationale
Sterile gloves are donned after the nurse has established the sterile field, draped the client, and organized the supplies, and immediately before touching the sterile catheter and the client's meatus for insertion. Donning gloves too early increases the risk of contamination from touching non-sterile surfaces while setting up the field.
Choice D rationale
The urinary meatus should be cleansed using a minimum of three separate antiseptic-soaked cotton swabs or balls. Cleansing starts with the most distant area (far side), then the closest area (near side), and finally directly over the meatus, using a single downward stroke for each area. Using only one swab significantly increases the risk of infection.
Correct Answer is D
Explanation
Choice A rationale
Dioctyl sodium sulfosuccinate, or docusate sodium, is a stool softener that works by lowering the surface tension of stool, allowing water and lipids to penetrate the fecal mass more easily. This action helps to soften the stool and ease its passage, promoting regular bowel movements, not decreasing the frequency of diarrhea, which is already characterized by loose stools.
Choice B rationale
Docusate sodium is a type of laxative and is not indicated or effective for the relief of nausea. Nausea is a symptom of many underlying conditions and is treated with antiemetic medications. The mechanism of action for stool softeners relates purely to water absorption and softening the stool in the large intestine.
Choice C rationale
Docusate sodium works to prevent constipation and facilitate easier bowel elimination by softening the stool, thereby promoting more frequent and comfortable defecation. The intended effect is an increase in the ease and regularity of bowel movements, not a decrease in the number of bowel movements, which would be an undesirable outcome.
Choice D rationale
As a stool softener, the intended therapeutic effect of docusate sodium is to make bowel movements easier and more consistent. By drawing water into the stool, it prevents the formation of hard, dry stools that cause constipation, thereby achieving the desired outcome of regular, soft, and easily passed bowel movements without stimulating peristalsis.
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