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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Diaphragmatic respirations are normal in infants and do not necessarily indicate acute respiratory distress.
Choice B rationale
A resting respiratory rate of 35 breaths/min is within the normal range for a 4-month-old infant and does not necessarily indicate acute respiratory distress.
Choice C rationale
Bilateral bronchial breath sounds are normal findings and do not necessarily indicate acute respiratory distress.
Choice D rationale
Flaring of the nares, or nostrils, is a sign of respiratory distress in children. It indicates that the child is having to work harder to breathe.
Correct Answer is B
Explanation
Choice A rationale
Production of extra platelets is not the primary pathophysiological process in Disseminated Intravascular Coagulation (DIC). While the body may try to produce more platelets in response to the widespread clotting, this is not the cause of the coagulation problem.
Choice B rationale
Depletion of clotting factors is a key feature of DIC. In the initial phase of DIC, there is an overactive clotting process leading to the formation of small blood clots throughout the body’s blood vessels. This overactive clotting uses up platelets and clotting factors, leading to a state where the body is unable to control bleeding, which is the second phase of DIC34.
Choice C rationale
Inhibition of red blood cell production is not a primary feature of DIC. While DIC can lead to anemia due to blood loss from excessive bleeding, it does not directly inhibit the production of red blood cells.
Choice D rationale
Activation of complement pathways is part of the body’s immune response and is not the primary cause of the coagulation problem in DIC34.
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