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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 D

Explanation

Choice A reason: A hemoglobin level of 16 g/dL is within the normal range and does not indicate acute kidney injury.

Choice B reason: A BUN level of 15 mg/dL is also within the normal range and does not suggest acute kidney injury.

Choice C reason: A serum potassium level of 4.5 mEq/L is within the normal range and is not indicative of acute kidney injury.

Choice D reason: A serum creatinine level of 6 mg/dL is significantly elevated and indicates impaired kidney function, which is a hallmark of acute kidney injury.

A. Maintain the client in a left lateral position during dialysis. B. Monitor vital signs every 2 hours during the procedure. C. Warm the dialysate solution prior to instillation. D. Place the drainage bag above the level of the client's abdomen.

Correct Answer is C

Explanation

Choice A reason: Maintaining the client in a left lateral position is not specifically required for peritoneal dialysis. Positioning may vary based on the individual's comfort and specific medical needs.

Choice B reason: While monitoring vital signs is important during any medical procedure, it is not an intervention that directly ensures proper dialysate exchange in peritoneal dialysis.

Choice C reason: Warming the dialysate solution prior to instillation is a standard practice in peritoneal dialysis. It helps to promote patient comfort and more efficient exchange of wastes and fluids.

Choice D reason: Placing the drainage bag above the level of the client's abdomen would impede gravity drainage, which is necessary for proper dialysate exchange. The drainage bag should be placed below the level of the client's abdomen.

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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

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Correct Answer is D

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Correct Answer is C

Explanation

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