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 B
Explanation
Choice A rationale
An ileal conduit does not provide the client with control over elimination. It is a type of urinary diversion, and the client wears an external pouch to collect urine.
Choice B rationale
In an ileal conduit, the client's ureters are attached to a section of the small intestine, which is then brought to the surface of the abdomen to form a stoma. Urine flows through this conduit into an external pouch.
Choice C rationale
An ileal conduit is not a tube that directly connects the kidney to an external pouch. It involves using a section of the small intestine to create a passageway for urine to exit the body.
Choice D rationale
Stool is not passed through an ileal conduit. The ileal conduit is specifically for urinary diversion, while stool passes through the regular gastrointestinal tract.
Correct Answer is D
Explanation
Choice A rationale
Clients should be instructed to hold their breath for about 10 seconds after inhalation, not 2 seconds. This allows the medication to reach deeper into the lungs.
Choice B rationale
The MDI canister should not be washed after each use. Instead, it should be cleaned regularly to ensure proper functioning and avoid medication buildup.
Choice C rationale
Clients should be instructed to inhale the medication slowly and deeply over a few seconds, rather than quickly for 1 second. This ensures proper delivery of the medication to the lungs.
Choice D rationale
Shaking the MDI prior to administration is essential. This action mixes the medication evenly, ensuring that the correct dose is delivered with each puff.