Nokea
A nurse teaches a client about performing intermittent self-catheterization. The client states, 'I am not sure if I will be able to afford these catheters.' How should the nurse respond?
- A. You may qualify for financial assistance; let's discuss options with a social worker.
- B. Even though it is expensive, the cost of taking care of urinary tract infections would be even higher.
- C. Instead of purchasing new catheters, you can boil the catheters and reuse them up to 10 times each.
- D. You can reuse the catheters at home. Clean technique, rather than sterile technique, is acceptable.
Correct Answer: D
Rationale: Using clean technique for intermittent self-catheterization at home is sufficient to prevent urinary tract infections and reduces costs by allowing catheter reuse after proper cleaning. Referring to a social worker for financial concerns is appropriate but not the most direct response to the client's concern. Boiling catheters is not a recommended practice, and emphasizing the cost of infections may cause anxiety without addressing the issue.
You may also like to solve these questions
A nurse is caring for clients as a member of the rehabilitation team. Which activities should the nurse perform? (Select all that apply.)
- A. Maintain the safety of adaptive devices by monitoring their function and making repairs.
- B. Coordinate rehabilitation team activities to ensure implementation of the plan of care.
- C. Assist clients to identify support services and resources for the continuation of services.
- D. Counsel clients and family members on strategies to cope with disability.
- E. Support the clients' choices by acting as an advocate for the client and family.
Correct Answer: B,E
Rationale: The rehabilitation nurse coordinates team activities to ensure the plan of care is implemented and advocates for the client and family. Maintaining adaptive devices is the role of a biomedical technician, assisting with support services is the social worker's role, andcounseling on coping strategies is handled by a clinical psychologist.
A rehabilitation nurse cares for a client who has generalized weakness and needs assistance with activities of daily living. Which exercise should the nurse implement?
- A. Passive range of motion
- B. Active range of motion
- C. Resistive range of motion
- D. Aerobic exercise
Correct Answer: B
Rationale: Active range of motion exercises promote strength, range of motion, and independence with activities of daily living, making them appropriate for a client with generalized weakness. Passive range of motion is suitable for clients unable to move independently, resistive range of motion may be too strenuous, and aerobic exercise may not directly address the client's need for improved daily function.
A nurse plans care for a client who is bedridden. Which assessment should the nurse complete to ensure to prevent pressure ulcer formation?
- A. Nutritional intake and serum albumin levels
- B. Pressure ulcer diameter and depth
- C. Wound drainage, including color, odor, and consistency
- D. Dressing site and antibiotic ointment application
Correct Answer: A
Rationale: Assessing nutritional intake and serum albumin levels helps determine the client's nutritional status, which is critical for preventing pressure ulcers, as poor nutrition can impair skin integrity. The other options focus on treating existing pressure ulcers rather than preventing their formation.
A rehabilitation nurse cares for a client who is wheelchair bound. Which intervention should the nurse implement to prevent skin breakdown?
- A. Place pillows under the client's heels.
- B. Have the client do wheelchair push-ups.
- C. Perform wound care as prescribed.
- D. Massage the client's calves and feet with lotion.
Correct Answer: B
Rationale: Clients who are wheelchair-bound should perform wheelchair push-ups for at least 10 seconds every hour to relieve pressure on weight-bearing areas, reducing the risk of skin breakdown. Pillows under the heels may increase pressure, wound care treats existing ulcers, and massaging the calves in clients with decreased mobility risks embolization.
A nurse is caring for a client who has a spinal cord injury at level T3. Which intervention should the nurse implement to assist with bladder dysfunction?
- A. Insert an indwelling urinary catheter.
- B. Stroke the medial aspect of the thigh.
- C. Use the Credé maneuver every 3 hours.
- D. Apply a Texas catheter with a leg bag.
Correct Answer: C
Rationale: The Credé maneuver, which involves applying manual pressure to the bladder, can facilitate voiding in clients with a flaccid bladder due to a spinal cord injury at T3. Indwelling catheters increase the risk of urinary tract infections and are generally avoided. Stroking the medial thigh is used for upper motor neuron issues, not flaccid bladders. A Texas catheter is unsuitable as the client may be unaware of a full bladder and unable to control voiding.