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.)

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.

Choice A reason: Ensuring the client's urine output is at least 1 mL/kg/hour is important before administering potassium to prevent hyperkalemia, especially in clients with renal impairment.

Choice B reason: While educating the client about high-potassium food sources is important, it is not directly related to the administration of intravenous potassium.

Choice C reason: Cardiac monitoring during infusion is crucial due to the risk of arrhythmias associated with rapid

changes in potassium levels.

Choice D reason: Repeating blood serum potassium is necessary to monitor the effectiveness of the supplementation and avoid hyperkalemia.

Choice E reason: Potassium should not be prepared with 5% dextrose solution as it may cause a trans-cellular shift of potassium into cells, which is not recommended.