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A nurse is caring for older adult clients at a long-term care facility. Which of the following assessments should the nurse consider when monitoring clients for urinary retention? (Select all that apply.)

Dribbling of urine

Color of the urine

Voiding patern

Proteinuria

Bladder distension

Answer and Explanation

Correct Answer : A,C,E

Choice A reason: Dribbling of urine can indicate urinary retention, as it may suggest that the bladder is not emptying

completely during voiding.

Choice B reason: While the color of the urine can provide information about hydration status and other health issues, it is not a direct indicator of urinary retention.

Choice C reason: The voiding patern is an important assessment for urinary retention. Infrequent voiding or small amounts despite a full bladder can be signs of this condition.

Choice D reason: Proteinuria is not typically used as an assessment for urinary retention. It can indicate kidney damage or disease but does not directly relate to the bladder's ability to empty.

Choice E reason: Bladder distension can be observed and palpated in cases of urinary retention, as the bladder may become enlarged due to the accumulation of urine.

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Correct Answer is ["B","D","E","F"]

Explanation

Choice A reason: Frothy urine is not a typical symptom of pyelonephritis; it is more associated with proteinuria or nephrotic syndrome.

Choice B reason: Lower abdominal pain can be a symptom of pyelonephritis due to in?ammation and infection in the kidneys.

Choice C reason: Hypertension is not a direct symptom of pyelonephritis, although it can be associated with chronic kidney disease.

Choice D reason: A fish-type urine odor can be present in pyelonephritis due to the presence of bacteria.

Choice E reason: Mental confusion can occur, especially in severe cases or in elderly patients with pyelonephritis.

Choice F reason: A weak urine stream may be present if there is swelling or obstruction in the urinary tract due to infection.

A. pH 7.26, HCO3 24, PaCO2 46 B. pH 7.49, HCO3 30, PaCO2 40 C. pH 7.49, HCO3 24, PaCO2 30 D. pH 7.26, HCO3 14, PaCO2 30

Correct Answer is D

Explanation

Choice A reason: A pH of 7.26 indicates acidosis, but an HCO3 of 24 and PaCO2 of 46 suggest a respiratory cause rather than metabolic, which is not typical for AKI.

Choice B reason: A pH of 7.49 indicates alkalosis, and with an HCO3 of 30 and PaCO2 of 40, this suggests metabolic alkalosis, which is not expected in AKI.

Choice C reason: A pH of 7.49 indicates alkalosis. An HCO3 of 24 is normal, and a PaCO2 of 30 would suggest respiratory alkalosis, not typically associated with AKI.

Choice D reason: A pH of 7.26 indicates acidosis, and with an HCO3 of 14, this suggests metabolic acidosis, which is consistent with AKI. The PaCO2 of 30 indicates a compensatory respiratory response to the metabolic acidosis. This ABG result aligns with the expected findings in a patient with AKI, where there is an accumulation of acids and a decrease in bicarbonate due to the kidneys' inability to filter and excrete hydrogen ions effectively.

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A nurse is caring for older adult clients at a long-term care facility. Which of the following assessments should the nurse consider when monitoring clients for urinary retention? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who has pyelonephritis. Which of the following manifestations should the nurse expect to be present during the assessment? (Select all that apply.)

Correct Answer is ["B","D","E","F"]

Explanation

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Correct Answer is D

Explanation

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