A nurse is collecting data on a client who has urinary retention. Which of the following findings should the nurse expect?
Leakage of urine
Dark-colored urine
Cloudy urine
Blood in urine
The Correct Answer is A
Choice A reason: Leakage of urine is a sign of urinary retention, as it indicates that the bladder is overdistended and unable to empty completely. The urine may leak around the urethra or through a catheter.
Choice B reason: Dark-colored urine is not a sign of urinary retention. It can be caused by dehydration, certain foods or medications, or liver or kidney problems.
Choice C reason: Cloudy urine is not a sign of urinary retention. It can be caused by infection, inflammation, or stones in the urinary tract.
Choice D reason: Blood in urine is not a sign of urinary retention. It can be caused by trauma, infection, cancer, or coagulation disorders in the urinary tract.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A heart murmur is a common finding in clients who have mitral valve stenosis. It is a sound produced by turbulent blood flow through the narrowed valve. The murmur is usually heard as a low-pitched rumbling sound during diastole.
Choice B reason: Bradycardia is not a typical finding in clients who have mitral valve stenosis. Bradycardia is a slow heart rate, usually below 60 beats per minute. Mitral valve stenosis can cause tachycardia, which is a fast heart rate, due to increased cardiac workload and reduced cardiac output.
Choice C reason: Clubbing of the fingers is not a sign of mitral valve stenosis. Clubbing is a deformity of the fingertips and nails that occurs due to chronic hypoxia. Mitral valve stenosis can cause pulmonary hypertension and pulmonary edema, which can impair gas exchange, but not to the extent of causing clubbing.
Choice D reason: Barrel chest is not a sign of mitral valve stenosis. Barrel chest is a condition where the chest is enlarged and rounded due to chronic lung disease. Mitral valve stenosis can affect the lungs by increasing the pressure in the pulmonary circulation, but it does not cause structural changes in the chest wall.
Correct Answer is C
Explanation
Choice A reason: Storing oxygen tanks upright is not a necessary instruction for home oxygen therapy. Oxygen tanks can be stored horizontally or vertically, as long as they are secured and away from heat sources.
Choice B reason: Using petroleum-based ointments to moisturize lips is not advisable for clients who use home oxygen therapy. Petroleum-based products can ignite in the presence of oxygen and cause burns. The nurse should recommend water-based products instead.
Choice C reason: Keeping oxygen tanks 4 feet away from an electric stove is a safety measure for home oxygen therapy. Oxygen is a flammable gas and can cause a fire or explosion if exposed to heat or sparks. The nurse should also instruct the client to avoid smoking, candles, and other open flames.
Choice D reason: Choosing a wool blanket when using oxygen is not a good idea for home oxygen therapy. Wool is a synthetic material that can generate static electricity and ignite oxygen. The nurse should suggest cotton or other natural fabrics instead.
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