A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention?

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Asking if the patient feels the need to go to the bathroom helps assess urgency. 2. Urinary retention may lead to the inability to sense the urge to void. 3. This question directly addresses the issue of voiding, crucial in diagnosing urinary retention. Summary: B: Mobility is not directly related to urinary retention. C: Medication timing is important but not directly related to urinary retention. D: Safety rail inquiry is more related to fall prevention, not urinary retention.

Correct Answer: A

Rationale: The correct answer is A: Teaches proper handwashing technique. This is the most appropriate intervention because proper handwashing can help prevent the spread of infection, including urinary infections. Teaching the patient about handwashing empowers them to take control of their own hygiene, reducing the risk of infection. Summary of why other choices are incorrect: B: Properly cleans the patient's toilet - While important for maintaining cleanliness, this does not directly address the patient's risk for a urinary infection. C: Transports urine specimen to the lab - This is not a direct care intervention for preventing urinary infections. D: Informs the oncoming nurse during hand-off - Hand-off communication is important for continuity of care but does not directly address the patient's risk for a urinary infection.

Correct Answer: A

Rationale: The correct answer is A: Identify factors interfering with goal achievement. This is the priority action because it focuses on understanding what caused the patient to fall despite the goal of preventing falls. By identifying the factors interfering with goal achievement, the nurse can make necessary adjustments to the care plan to prevent future falls. Choice B is incorrect because counseling the nursing assistive personnel and removing the fall risk sign does not address the root cause of the fall. Choice C is incorrect because shifting responsibility to the charge nurse for documentation does not address the immediate need to assess and address the factors contributing to the fall. Choice D is incorrect because documenting the fall is important but not the priority when the immediate concern is understanding why the fall occurred.

Correct Answer: B

Rationale: The correct answer is B because it encourages the patient to share any additional information they may have forgotten or overlooked, ensuring a thorough health history interview. Choice A is incorrect as it implies the interviewer is unprepared or disinterested. Choice C is inappropriate as it may make the patient feel guilty or inadequate. Choice D is incorrect as it does not address the possibility of gathering more relevant information from the patient.

Correct Answer: A

Rationale: The correct answer is A because assessment data should be collected continuously to ensure timely detection of any changes in the client's condition. This allows for prompt interventions and prevents complications. Choice B is incorrect as assessment should be ongoing and not limited to specific times. Choice C is incorrect as the frequency of assessment should be based on client needs, not a fixed schedule. Choice D is incorrect as assessments should not be limited to certain times but should be ongoing to provide comprehensive care.