Which of the following nursing interventions is most specific for a client being monitored for possible urinary retention?
1. Measuring urine output with each urination
2. Monitoring the color and clarity of urine with each voiding
3. Collecting a urine sample for a culture and sensitivity test
4. Asking the cognizant client to report each time he or she urinates
ANS: 4
With retention the client may void small amounts of urine 2 or 3 times an hour with no real relief of discomfort or may continually dribble urine. Be aware of the volume and frequency of voiding to assess this condition in the client. The alert, oriented client can be asked to notify the nurse each time micturition occurs. The remaining options are more generalized or specific for a urinary tract infection.
You might also like to view...
Criteria established for the diagnosis of dementia include: (Select all that apply.)
a. evidence of cognitive deficits. b. evidence of aphasia, apraxia, or agnosia. c. impairment in social function. d. impairments of occupational function. e. neurologic signs and symptoms, such as ataxic gait.
SBAR communication stands for __________
a. situation, breathing, airway, and respirations b. situation, background, assessment, and recommendation c. situation, background, action, and recommendation d. situation, breathing, assessment, and recommendation
A community/public health nurse was responsible for setting up a health fair in a very heavily attended inner-city church, with several screenings being given simultaneously. Within the public health agency, what would the nurse call the health fair?
A. Case finding B. Community service C. Multiphasic screening D. Unreimbursed care
A nurse on the unit notices that a co-worker exhibits a pattern of behavior suggestive of drug abuse. The nurse should:
1. Report the situation to the unit charge nurse. 2. Send an anonymous letter to the director of nursing. 3. Let other co-workers know about the situation. 4. Report the situation, then let management take care of it.