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A nurse is assessing a client who has urinary retention.
Which of the following findings should the nurse expect?

A.

Blood in urine.

B.

Cloudy urine.

C.

Dark-colored urine.

D.

Leakage of urine.

Answer and Explanation

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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View Related questions

Correct Answer is D

Explanation

Choice A rationale

Hypothermia is not commonly associated with diarrhea. Diarrhea typically leads to fluid loss and dehydration rather than changes in body temperature.

Choice B rationale

A rigid abdomen is not a typical finding for diarrhea. It may indicate other gastrointestinal issues, such as peritonitis, rather than dehydration caused by diarrhea.

Choice C rationale

Decreased bowel sounds are not typically expected with diarrhea, which often presents with increased bowel sounds due to increased motility.

Choice D rationale

Dehydration is a common finding in clients with diarrhea due to the excessive loss of fluids and electrolytes from frequent, loose stools. It can lead to symptoms such as dry mouth, reduced urine output, and dizziness.

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.

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