Which assessment technique would provide the most useful data when the nurse is concerned about possible urinary retention?
Auscultate an area six inches below the umbilicus.
Observe the appearance of the patient’s urine.
Palpate the area above the pubic symphysis.
Measure the girth of the patient’s lower abdomen.
The Correct Answer is C
Choice A rationale
Auscultating an area six inches below the umbilicus would not provide the most useful data when assessing for possible urinary retention. Auscultation is typically used to assess bowel sounds and not typically used in the assessment of urinary retention.
Choice B rationale
Observing the appearance of the patient’s urine can provide some information about the patient’s hydration status and kidney function, but it would not be the most useful technique for assessing urinary retention.
Choice C rationale
Palpating the area above the pubic symphysis can provide useful data when assessing for possible urinary retention. If the bladder is distended due to urinary retention, it may be palpable in this area.
Choice D rationale
Measuring the girth of the patient’s lower abdomen is not typically used as a method to assess for urinary retention. While an increase in abdominal girth can occur with urinary retention, it is not the most direct or reliable method for assessment.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
Keeping the infant home from daycare for the next two days after vaccination is not necessary unless the child is showing signs of serious side effects, which are rare. Most vaccines have mild side effects such as soreness at the injection site or a mild fever, which should not interfere with the child’s daily activities.
Choice B rationale
Applying a cool, damp cloth or a cool pack to the injection site can help reduce redness, soreness, and/or swelling. This is a common practice recommended by healthcare professionals to alleviate discomfort after vaccination.
Choice C rationale
It is not recommended to administer aspirin to children due to the risk of Reye’s syndrome, a rare but serious condition that can affect the liver and brain. Instead, if the child is uncomfortable or has a fever, parents can consult with a healthcare provider about giving a non-aspirin pain reliever.
Choice D rationale
While any level of fever after vaccination should be monitored, it is not always serious and should not cause panic. Fevers are a common side effect of vaccinations and are usually a sign that the body is building protection against the virus or bacteria in the vaccine. However, if a high fever persists or the child shows signs of an allergic reaction, parents should contact a healthcare provider immediately.
Correct Answer is C
Explanation
Choice A rationale
While the frequency of a problem can provide some context, it is not the most important consideration when gathering evidence for evidence-based decision-making. The frequency of a problem does not necessarily correlate with the quality or relevance of the evidence available.
Choice B rationale
Personal values are important in decision-making processes, but they are subjective and can vary greatly among individuals. Therefore, they are not the most important consideration when gathering objective, scientific evidence for evidence-based practice.
Choice C rationale
Relevance to the situation is the most important consideration when gathering evidence. Evidence must be directly applicable to the specific problem and context in order to be useful in informing decision-making. This includes considering the specific characteristics of the patient population, the nature of the problem, and the setting in which care is being provided.
Choice D rationale
Past experience with similar problems can provide valuable insights and context, but it is not the most important consideration. Past experiences are individual and subjective, and what worked in one situation may not work in another. Evidence-based practice requires the use of current, high-quality research evidence, which may or may not align with past experiences.
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