The nurse cares for a client on the medical-surgical floor. Which finding places the client at greatest risk for urinary retention?
The client with a history of frequent urinary tract infections.
The client has had 32 mL of urine output in the last hour.
The client with an elevated blood pressure and headache.
The client had a surgical procedure requiring general anesthesia.
The Correct Answer is D
Rationale:
A. A client with a history of frequent urinary tract infections (UTIs) does have some risk for complications related to the urinary system, such as recurrent infections or bladder irritation. However, this history does not directly cause acute urinary retention. While monitoring is important, the client is not at the highest immediate risk for retention compared to others with more direct risk factors.
B. A urine output of 32 mL in the last hour is considered low (oliguria), and while it warrants close observation, it does not automatically indicate urinary retention. Oliguria can result from dehydration, hypovolemia, or decreased kidney function, but urinary retention specifically refers to the inability to empty the bladder despite the presence of urine and often the urge to void.
C. A client with elevated blood pressure and headache may be experiencing hypertension or other cardiovascular issues, but these symptoms are not primary risk factors for urinary retention. While hypertension can affect kidney function long-term, it does not acutely prevent bladder emptying.
D. A client who has undergone a surgical procedure requiring general anesthesia is at the greatest risk for urinary retention. General anesthesia can depress the central nervous system and inhibit bladder contractility, reducing the sensation of bladder fullness and delaying the ability to void postoperatively. Postoperative urinary retention is a common complication, especially after procedures involving the pelvic area or when opioids are used for pain management. This makes careful monitoring, assessment of bladder distention, and interventions such as bladder scanning or catheterization critical for preventing complications like bladder overdistension or infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Humidification is the correct intervention to reduce irritation to the mucous membranes in clients receiving supplemental oxygen. When oxygen is delivered at higher flow rates or for extended periods, it is typically dry, which can cause dryness and irritation of the nasal passages, throat, and airway. This can lead to discomfort, nosebleeds, increased mucus thickness, and even damage to the delicate mucosal lining. Adding a humidifier to the oxygen delivery system introduces moisture into the oxygen stream, helping maintain mucosal hydration, improve comfort, and reduce the risk of complications. Humidification can be especially important for clients on high-flow oxygen, long-term oxygen therapy, or those with preexisting respiratory conditions.
B. A filtering device, such as a bacterial or particulate filter, is designed to remove impurities, contaminants, or microorganisms from the oxygen supply. While filters improve the safety and cleanliness of the oxygen, they do not address dryness or prevent irritation of the mucous membranes.
C. Cooling agents are not used in oxygen therapy. Cooling the oxygen or air does not prevent dryness and may even exacerbate mucosal discomfort. This is not a recommended method for protecting mucous membranes.
D. Medication is not routinely added to oxygen systems to prevent mucosal irritation. Medications delivered via oxygen would only be used for specific therapeutic purposes, such as bronchodilation or nebulized therapy, and are not a general intervention for dryness or irritation.
Correct Answer is B
Explanation
Rationale:
A. Placing the client on oxygen using a nasal cannula is part of the administration process, but it should not be done before completing a baseline assessment. Starting oxygen without assessing the client could mask changes in respiratory status or lead to inappropriate therapy.
B. Performing a respiratory assessment and obtaining vital signs is the correct next action. A baseline assessment—including respiratory rate, oxygen saturation, lung sounds, work of breathing, and overall vital signs—allows the nurse to evaluate the client’s current oxygenation status and determine the appropriate oxygen delivery method and flow rate. This step also provides a reference point for monitoring the effectiveness and safety of therapy.
C. Ensuring the nasal cannula is positioned securely is important but occurs after determining the correct flow rate and delivery method based on the assessment and order. Proper placement alone does not ensure safe or effective oxygen therapy.
D. Observing for changes in level of consciousness or behavior is part of ongoing monitoring but is not the first action. Baseline assessment must be completed first to identify deviations from the client’s usual status and guide safe oxygen administration
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