Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

Auscultate an area six inches below the umbilicus.

Palpate the area above the pubic symphysis.

Measure the girth of the client's lower abdomen.

Observe the appearance of the client's urine.

Answer and Explanation

The Correct Answer is B

A. Auscultating below the umbilicus is not effective for assessing urinary retention.

B. Palpating the area above the pubic symphysis allows the nurse to assess for bladder distention, which is a direct indicator of urinary retention.

C. Measuring the girth of the lower abdomen can be useful but is less specific than palpation for assessing bladder fullness.

D. Observing the urine's appearance does not directly assess for urinary retention.

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Correct Answer is C

Explanation

A. While the nurse should be aware of the gap, they must first complete the assessment rather than stopping at this point.

B. Repositioning the stethoscope is not necessary if the sounds are heard clearly.

C. Thenurse should not stop or make assumptions but should continue listening to detect the reappearance of Korotkoff sounds and obtain an accurate diastolic reading.

D. Re-inflating the cuff to a higher number is unnecessary unless the initial reading was unclear or the cuff was under-inflated.

A. Report any increase the white blood cell count. B. Wear a face mask while performing wound care. C. Instruct the family to adhere to contact precautions. D. Change the surgical dressing readily when soiled.

Correct Answer is D

Explanation

A. While reporting an increase in white blood cell count is important, it is more a sign of infection rather than a direct preventive measure.

B. Wearing a face mask can help prevent respiratory spread but is less critical for MRSA, which is typically spread by direct contact.

C. Instructing the family to adhere to contact precautions is important but not the primary action.

D. Changing the surgical dressing when soiled is crucial to prevent contamination and potential infection of the wound, directly reducing the risk of MRSA recurrence.

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Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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