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
Replacing the external urinary catheter once each day is unnecessary. The catheter should be changed based on clinical judgment and manufacturer's guidelines to maintain hygiene.
Choice B rationale
Inserting the catheter into the client's urethra is incorrect for an external urinary catheter. External catheters are designed to be placed outside the body.
Choice C rationale
Applying a barrier cream to the client's perineal skin is correct. Barrier creams protect the skin from moisture and prevent skin breakdown and irritation caused by urine.
Choice D rationale
Connecting the catheter to continuous wall suction is not appropriate. External urinary catheters should be connected to a drainage bag for proper urine collection. .
Correct Answer is C
Explanation
Choice A rationale
Reducing daily activity is not advised for clients with constipation. Physical activity helps stimulate bowel movements and can relieve constipation.
Choice B rationale
Trying to defecate at different times of the day is not recommended. Establishing a regular bowel routine helps promote consistent bowel movements and can prevent constipation.
Choice C rationale
Increasing daily fluid intake is beneficial for constipation. Fluids help soften stool, making it easier to pass and promoting regular bowel movements.
Choice D rationale
Consuming a low-fiber diet is not advisable for clients with constipation. A high-fiber diet helps bulk up and soften stool, making it easier to pass through the intestines.