Nokea
A nurse is implementing a bladder training program for a client who had a stroke. Which of the following interventions should the nurse take first?
- A. Assist the client with relaxation techniques.
- B. Discourage intake of carbonated beverages.
- C. Offer toileting opportunities every 1 to 2 hr.
- D. Determine the client's pattern for voiding.
Correct Answer: D
Rationale: Assessing the client's voiding pattern first provides baseline data to tailor the bladder training program, ensuring interventions like toileting schedules or dietary changes are effective.
You may also like to solve these questions
A nurse is reinforcing teaching with a client who has a new prescription for sertraline. Which of the following statements should the nurse include?
- A. You should take this medication in the morning.
- B. You might experience insomnia while taking this medication.
- C. You need to avoid caffeine while taking this medication.
- D. You should expect immediate improvement in your symptoms.
Correct Answer: B
Rationale: Sertraline can cause insomnia, a key side effect to anticipate. It's taken flexibly, caffeine isn't restricted, and effects take weeks.
A nurse is caring for a client who is receiving chemotherapy. Which of the following actions should the nurse take?
- A. Encourage the client to eat raw fruits and vegetables.
- B. Monitor the client's white blood cell count.
- C. Administer an antipyretic every 4 hr.
- D. Instruct the client to avoid handwashing.
Correct Answer: B
Rationale: Monitoring WBC count detects neutropenia, critical for infection prevention. Raw produce risks infection, antipyretics aren't routine, and handwashing is essential.
A nurse is reinforcing teaching about laboratory testing with a client. Which of the following findings should the nurse include as an indicator of infection?
- A. Decreased platelets
- B. Increased iron level
- C. Increased erythrocyte sedimentation rate
- D. Decreased hemoglobin
Correct Answer: C
Rationale: Increased ESR indicates inflammation, often due to infection. Platelet or hemoglobin decreases or iron increases aren't specific to infection.
A nurse is caring for a client who is receiving IV chemotherapy. Which of the following actions should the nurse take?
- A. Monitor the client's temperature every 4 hr.
- B. Administer the chemotherapy through a peripheral IV.
- C. Check the IV site for signs of infiltration.
- D. Encourage the client to avoid handwashing.
Correct Answer: C
Rationale: Checking for infiltration prevents extravasation, critical for chemotherapy safety. Temperature monitoring is routine, central lines are preferred, and handwashing is encouraged.
A nurse is assisting with the care of a client who is receiving a continuous tube feeding. Which of the following actions should the nurse take to prevent aspiration?
- A. Flush the tube with 30 mL of sterile water every 4 hr.
- B. Place the client in a supine position during feeding.
- C. Check for gastric residual volume every 4 hr.
- D. Keep the head of the bed elevated to at least 30 degrees.
Correct Answer: D
Rationale: Elevating the bed to 30-45 degrees reduces aspiration risk by promoting proper digestion. Flushing maintains patency, supine position increases risk, and residual checks monitor tolerance.