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 B
Explanation
Choice A reason: Respiratory rate 28/min is not a sign of effective oxygen therapy, as it indicates tachypnea, which is a rapid breathing rate. Tachypnea can be caused by hypoxia, anxiety, fever, or pain.
Choice B reason: Pink mucous membranes are a sign of effective oxygen therapy, as they indicate adequate oxygenation of the tissues. Pink mucous membranes are a normal finding, while pale, cyanotic, or jaundiced mucous membranes can indicate hypoxia or other problems.
Choice C reason: Heart rate 110/min is not a sign of effective oxygen therapy, as it indicates tachycardia, which is a rapid heart rate. Tachycardia can be caused by hypoxia, stress, dehydration, or infection.
Choice D reason: Restlessness is not a sign of effective oxygen therapy, as it indicates agitation, anxiety, or discomfort. Restlessness can be caused by hypoxia, pain, or medication side effects.
Correct Answer is A
Explanation
The correct answer is: A. Place the client on continuous cardiac monitoring.
Choice A reason:
Placing the client on continuous cardiac monitoring is crucial because metabolic alkalosis can lead to life-threatening arrhythmias due to electrolyte imbalances, particularly hypokalemia. Continuous monitoring allows for the early detection and management of these arrhythmias, ensuring patient safety.
Choice B reason:
Obtaining a prescription for insulin is not relevant for treating metabolic alkalosis. Insulin is typically used for managing hyperglycemia and diabetic ketoacidosis, not for correcting alkalosis.
Choice C reason:
Planning to administer sodium bicarbonate is incorrect because sodium bicarbonate is used to treat metabolic acidosis, not alkalosis. Administering it in this context could worsen the alkalosis.
Choice D reason:
Having the client breathe into a paper bag is a technique used for respiratory alkalosis to increase CO2 levels. It is not appropriate for metabolic alkalosis, which requires different management strategies.
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