HESI RN Exit Proctored Exam
Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?
Explanation & Rationale
A. Auscultation is generally used to assess bowel sounds or lung sounds, not urinary retention. B. Measuring girth may be useful for assessing ascites or other fluid retention but is not specific to urinary retention. C. Observing the appearance of urine is not directly useful for detecting retention. Retention is about the inability to void despite the urge, and urine may or may not be visibly affected. D. Palpation above the pubic symphysis is the most effective way to assess for urinary retention because the bladder is located in this area. A distended bladder, which is a sign of retention, can often be palpated here.
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