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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Renal failure is typically associated with abnormal creatinine and BUN levels, which are not
indicated in the given lab values.
Choice B reason: A low-protein diet is not directly indicated by the lab values provided and does not typically result in
collapse after exertion.
Choice C reason: Dehydration is consistent with the client's history of collapsing after playing football on a hot day
and is supported by the elevated sodium level.
Choice D reason: SIADH usually presents with low sodium levels due to dilution, which is not the case here.
Correct Answer is D
Explanation
Choice A rationale: Cantaloupe is high in potassium. Clients with acute kidney injury (AKI) have impaired potassium excretion, and consuming high-potassium foods increases the risk of hyperkalemia, which can lead to cardiac arrhythmias.
Choice B rationale: Baked potatoes contain significant potassium, especially in the skin. In AKI, potassium retention is dangerous, so this choice reflects poor understanding of dietary restrictions for renal safety.
Choice C rationale: Yogurt is rich in potassium and phosphorus. In AKI, both electrolytes may accumulate due to reduced renal clearance, making yogurt an inappropriate choice without close monitoring.
Choice D rationale: Pecans are low in potassium, making them a safer snack for clients with AKI. Choosing low-potassium foods demonstrates appropriate understanding of renal dietary management.
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