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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: The nurse is not providing surgical site or wound care by documenting urination.

Choice B reason: Managing postoperative pain is not directly related to monitoring the client's ability to urinate.

Choice C reason: Assisting with early ambulation does not pertain to the urinary function directly.

Choice D reason: Monitoring urinary function is part of postoperative care, especially after removal of a Foley catheter, to ensure the client is able to void normally.

A. Hemoglobin 16 g/dL B. BUN 15 mg/dL C. Serum potassium 4.5 mEq/L D. Serum creatinine 6 mg/dL

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.

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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

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