A nurse is collecting data on a client who has urinary retention.
What findings should the nurse expect?
Leakage of urine
Dark-colored urine
Cloudy urine
Blood in urine
The Correct Answer is A
Choice A rationale:
Urinary retention is a condition where the bladder doesn’t empty all the way or at all when you urinate. This can lead to leakage of urine, as the bladder is overfilled and may result in small amounts of urine escaping. This symptom is often associated with urinary retention and is therefore a likely finding in a client with this condition.
Choice B rationale:
Dark-colored urine is not typically a direct symptom of urinary retention. It can be a sign of dehydration, certain dietary factors, or a side effect of some medications. While it’s possible for a person with urinary retention to have dark-colored urine, it’s not a specific or direct symptom of the condition.
Cloudy urine can be a sign of a urinary tract infection (UTI), which can occur as a complication of urinary retention. However, it’s not a direct symptom of urinary retention itself. A nurse would not necessarily expect to see cloudy urine in a client with urinary retention unless a UTI or another complication was present.
Choice D rationale:
Blood in the urine, or hematuria, is not a typical symptom of urinary retention. It can be a sign of various conditions, including UTIs, kidney stones, or more serious conditions like bladder or kidney disease. While it’s possible for a person with urinary retention to have blood in their urine, it’s not a direct symptom of the condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Administering insulin to a client who is hyperventilating due to respiratory alkalosis would not be the appropriate action. Insulin is used to lower blood glucose levels in clients with hyperglycemia, such as those with diabetes mellitus. It does not directly address the issues of hyperventilation or respiratory alkalosis.
Choice B rationale:
Having the client breathe into a paper bag is the correct action in this case. When a person hyperventilates, they exhale more carbon dioxide (CO2) than they produce. This can lead to a state of respiratory alkalosis, where the blood becomes too alkaline due to the low levels of CO2. By breathing into a paper bag, the client re-inhales some of the exhaled CO2, helping to restore the balance of gases in the blood and alleviate the symptoms of respiratory alkalosis.
Choice C rationale:
Administering sodium bicarbonate to a client who is hyperventilating and has respiratory alkalosis would not be the appropriate action. Sodium bicarbonate is an alkalinizing agent used to treat conditions where there is too much acid in the body, such as metabolic acidosis. In this case, the client’s body is too alkaline due to the respiratory alkalosis, so administering an alkalinizing agent would exacerbate the condition.
Choice D rationale:
Having the client place their head between their knees would not be the appropriate action for a client who is hyperventilating due to respiratory alkalosis. This position is often used to help alleviate symptoms of dizziness or fainting, but it does not address the underlying issue of the imbalance of gases in the blood due to hyperventilation.
Correct Answer is B
Explanation
Choice A rationale:
Administering insulin is a crucial step in managing diabetic ketoacidosis (DKA), as insulin deficiency is a primary cause of DKA12. However, it is not the first action to take when a patient presents with both DKA and hypoxia. While insulin helps to reduce blood glucose levels and suppress the production of ketones, it does not address the immediate life-threatening condition of hypoxia.
Choice B rationale:
Hypoxia, or low levels of oxygen in the body, is a medical emergency that requires immediate attention. Supplemental oxygen can help increase the oxygen levels in the patient’s blood, thereby alleviating hypoxia. In the context of a patient with DKA and hypoxia, providing supplemental oxygen would be the first action to take to stabilize the patient’s condition before addressing the DKA12.
Choice C rationale:
Checking the patient’s glucose level is an important part of managing DKA, as hyperglycemia is a key feature of this condition. However, it is not the first action to take in this scenario. While monitoring glucose levels can guide the administration of insulin and other treatments for DKA, it does not address the immediate threat posed by hypoxia.
Choice D rationale:
Administering intravenous fluids is another important step in managing DKA12. Dehydration is a common complication of DKA due to excessive urination caused by high blood sugar levels. However, similar to Choices A and C, while it is an important part of treatment, it is not the first action to take when a patient presents with both DKA and hypoxia.
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