A nurse is assessing a client who has urinary retention.
Which of the following findings should the nurse expect?
Blood in urine.
Cloudy urine.
Dark-colored urine.
Leakage of urine.
The Correct Answer is D
Choice A rationale
Blood in the urine (hematuria) is not a typical finding in urinary retention. It may indicate other conditions such as infection, stones, or malignancy.
Choice B rationale
Cloudy urine is often a sign of infection, not typically associated with urinary retention. It can be caused by the presence of bacteria, white blood cells, or crystals.
Choice C rationale
Dark-colored urine can result from dehydration or certain foods and medications. It is not a specific finding of urinary retention.
Choice D rationale
Leakage of urine, also known as overflow incontinence, can occur in urinary retention. This happens when the bladder becomes overly full, and small amounts of urine leak out due to the pressure.
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Correct Answer is C
Explanation
Choice A rationale
Returning the opened medication to the medication cart is inappropriate because once a medication is opened and refused by a client, it must be disposed of properly. This action helps maintain safety and prevents contamination.
Choice B rationale
Reporting the incident to the provider is not necessary in this context as the refusal to take medication can be managed by the nurse by following the facility's protocol.
Choice C rationale
Filling out an incident report is required because the client's refusal to take the medication is considered a significant event. Incident reports are used to document and analyze such events to improve patient care and safety.
Choice D rationale
Notifying the facility's ethics committee is unnecessary for a medication refusal incident, as it does not involve an ethical dilemma requiring their intervention.
Correct Answer is D
Explanation
Choice A rationale
It is best practice to use a new cotton swab for each swipe to avoid contamination. Each area should be cleaned with a separate cotton swab.
Choice B rationale
Oil-based lubricants should not be used with catheters as they can interfere with the material of the catheter. Water-based lubricants are preferred.
Choice C rationale
Testing the balloon on the indwelling urinary catheter before insertion can lead to an increased risk of contamination and potential damage to the catheter.
Choice D rationale
Sterile gloves are essential to prevent infection during the insertion of an indwelling urinary catheter. Maintaining a sterile field is crucial.