The nurse is able to percuss a dull tone over a client's bladder after the client has voided 300 ml of urine. The nurse would conclude which of the following is most likely the cause of this finding?
1. This is a normal finding
2. Possible urinary tract infection
3. This is a sign of prostate enlargement
4. Probable urinary retention
4
Rationale 1: This is not a normal finding as there should be little to no urine remaining in the bladder following urination. A dull percussion tone over the bladder of a client who has just urinated indicates urinary retention, and further evaluation is necessary.
Rationale 2: Little to no urine should remain in the bladder following urination. A dull percussion tone over the bladder of a client who has just urinated indicates urinary retention, and further evaluation is necessary. Urinary retention can lead to urinary tract infections, but this could not be concluded without additional testing.
Rationale 3: Little to no urine should remain in the bladder following urination. A dull percussion tone over the bladder of a client who has just urinated indicates urinary retention, and further evaluation is necessary Prostate enlargement usually affects the client's ability to start the urine flow and maintain a strong urine flow, so urinary retention would not indicate this condition.
Rationale 4: Little to no urine should remain in the bladder following urination. A dull percussion tone over the bladder of a client who has just urinated indicates urinary retention, and further evaluation is necessary.
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