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 B

Explanation

A. Identifying information as a late entry is not appropriate until the system issue is resolved.

B. Notifying the information services department is essential to address the system failure and seek assistance in resolving the issue.

C. Waiting for notification may delay addressing the problem and does not help in the immediate resolution.

D. Printing the EMR from the backup server might be necessary later but does not address the immediate need to fix the system issue.

A. Food contamination from flood waters. B. Close living quarters at evacuation centers. C. Nosocomial transmission in the medical area. D. Drinking water contaminated by sewage.

Correct Answer is D

Explanation

A. Food contamination from flood waters can lead to gastrointestinal issues, but in disaster scenarios, contaminated drinking water is a more common source of widespread diarrhea.

B. Close living quarters at evacuation centers can contribute to the spread of infectious diseases, but they are less likely to be the primary source of contamination compared to drinking water.

C. Nosocomial transmission in the medical area is possible but less likely to be the primary source of widespread diarrhea among disaster victims.

D. Drinking water contaminated by sewage is a common and significant source of gastrointestinal infections, especially in disaster scenarios where infrastructure may be compromised.

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Body System	Assessment Finding
Neurological	Restless Awake and alert Anxious
Respiratory	Respiratory rate 28 breaths/minute Oxygen Saturation 90% on room air Productive cough
Cardiovascular	Heart rate 101 beats/minute Capillary refill 4 seconds Blood pressure 145/89 mm Hg

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

Nursing Test Bank

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