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 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.
Correct Answer is D
Explanation
Choice D rationale
Dark-colored urine is a common indicator of dehydration. When the body is dehydrated, urine becomes more concentrated, leading to darker color due to higher levels of waste products.
Choice A rationale
Cloudy urine is not typically associated with dehydration. It may indicate the presence of an infection, inflammation, or other medical conditions.
Choice B rationale
Urine osmolality of 200 mOsm/kg suggests diluted urine, which is contrary to the expectation in dehydration. Dehydration would typically result in higher urine osmolality as the kidneys conserve water.
Choice C rationale
Urine specific gravity of 1.015 falls within the normal range (1.005 to 1.030). In dehydration, specific gravity would be expected to be higher as the urine becomes more concentrated to conserve water.