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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale:

Dry skin is not typically associated with respiratory alkalosis. Respiratory alkalosis occurs when the levels of carbon dioxide and oxygen in the blood aren’t balanced, often due to hyperventilation. Dry skin is not listed as a common symptom of this condition.

Choice B rationale:

Diarrhea is not a common symptom of respiratory alkalosis. The condition is characterized by symptoms such as dizziness, numbness, confusion, and shortness of breath. Diarrhea is more commonly associated with gastrointestinal issues rather than respiratory conditions.

Choice C rationale:

Abdominal pain is not a typical symptom of respiratory alkalosis. The condition is usually caused by over-breathing

(hyperventilation) that occurs when you breathe very deeply or rapidly. Abdominal pain is not listed as a common symptom of this condition.

Choice D rationale:

Hyperventilation is typically the underlying cause of respiratory alkalosis. Hyperventilation, also known as overbreathing, occurs when someone breathes very deeply or rapidly. This can cause the levels of carbon dioxide in the blood to drop too low, leading to respiratory alkalosis. Therefore, a nurse assessing a client who has respiratory alkalosis should expect to find signs of hyperventilation.

A. Respiratory rate 28/min. B. Pink mucous membranes. C. Heart rate 110/min. D. Restlessness. E. Restlessness.

Correct Answer is B

Explanation

Choice A rationale:

A respiratory rate of 28/min is not an indication that the intervention was effective. A normal respiratory rate for an adult at rest is between 12 and 20 breaths per minute. A respiratory rate of 28/min is considered tachypnea, which could be a sign of respiratory distress, not an improvement.

Choice B rationale:

Pink mucous membranes are a good sign. They indicate effective oxygenation and perfusion. When the body is receiving an adequate amount of oxygen, the skin, lips, and mucous membranes can appear pink. This is a positive outcome of oxygen therapy for hypoxia.

Choice C rationale:

A heart rate of 110/min is not an indication that the intervention was effective. A normal resting heart rate for adults ranges from 60 to 100 beats per minute. A heart rate of 110/min is considered tachycardia, which could be a sign of distress or compensation for hypoxia, not an improvement.

Choice D rationale:

Restlessness is not an indication that the intervention was effective. On the contrary, restlessness can be a sign of inadequate oxygenation. When the brain does not receive enough oxygen, a patient can become restless or anxious. Therefore, restlessness is not a positive outcome of oxygen therapy for hypoxia.

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A nurse is collecting data on a client who has urinary retention. What findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has respiratory alkalosis. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is assisting with the care of a patient who is receiving supplemental oxygen for hypoxia. Which of the following findings should the nurse identify as an indication that the intervention was effective?

Correct Answer is B

Explanation

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A nurse is collecting data on a client who has urinary retention.
What findings should the nurse expect?