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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
Select Response 1: First thing in the morning fasting
Monitoring blood glucose levels first thing in the morning while fasting helps assess the client’s baseline glucose level after an overnight fast. This is important for evaluating overall glucose control and adjusting treatment if necessary.
Select Response 2: Prior to each meal
Checking blood glucose levels before each meal provides insight into how well the client’s blood sugar is controlled throughout the day and helps adjust dietary and medication plans to maintain optimal glucose levels.
Correct Answer is ["C","D"]
Explanation
A. A bounding radial pulse does not specifically indicate the patency of an AV fistula; it is a general assessment of peripheral pulse quality.
B. Distended veins in the hand may indicate venous congestion but are not a reliable indicator of fistula patency.
C. The presence of a thrill (a palpable vibration) over the AV fistula indicates proper blood flow through the fistula.
D. The presence of a bruit (a whooshing sound) over the AV fistula indicates the flow of blood through the fistula, confirming patency.
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