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After delegating care to an unlicensed assistive personnel (UAP) for a client who is prescribed habit training to manage incontinence, a nurse evaluates the UAP's understanding. Which action indicates the UAP needs additional teaching?
- A. Toileting the client after breakfast
- B. Changing the client's incontinence brief when wet
- C. Encouraging the client to drink fluids
- D. Recording the client's incontinence episodes
Correct Answer: B
Rationale: Habit training is undermined by the use of absorbent incontinence briefs or pads. The nurse should re-educate the UAP on the technique of habit training. The UAP should continue to toilet the client after meals, encourage the client to drink fluids, and record incontinence episodes.
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A nurse teaches a client about self-catheterization in the home setting. Which statements should the nurse include in this client's teaching?
- A. Use a large human catheter for each catheterization.
- B. Use a large human catheter for each catheterization.
- C. Use lubricant on the tip of the catheter before insertion.
- D. Use lubricant on the tip of the catheter before insertion.
- E. Use lubricant on the tip of the catheter before insertion.
- F. Wash your hands with soap and water before and after catheterization.
- G. Use a clean catheter for each catheterization.
Correct Answer: C,F,G
Rationale: The nurse should teach the client to use lubricant on the tip of the catheter to ease insertion, wash hands with soap and water before and after catheterization to prevent infection, and use a clean catheter for each catheterization to maintain hygiene. Using a large catheter is not recommended as it may cause discomfort or injury.
A nurse teaches a young female client who is prescribed amoxicillin (Amoxil) for a urinary tract infection. Which statement should the nurse include in this client's teaching?
- A. Use a second form of birth control while on this medication.
- B. You will experience increased menstrual bleeding while on this drug.
- C. You will experience increased menstrual bleeding while on this drug.
- D. Watch for blood in your urine while taking this medication.
Correct Answer: A
Rationale: The client should use a second form of birth control because penicillin seems to reduce the effectiveness of estrogen-containing contraceptives. She should not experience increased menstrual bleeding or blood in her urine while taking this drug.
An emergency department nurse assesses a client with a history of urinary incontinence who presents with extreme dry mouth, constipation, and an inability to void. Which question should the nurse ask first?
- A. Are you drinking plenty of water?
- B. What medications are you taking?
- C. Have you tried laxatives or enemas?
- D. Has this type of thing ever happened before?
Correct Answer: B
Rationale: Some types of incontinence are treated with anticholinergic medications such as propantheline (Pro-Banthine). Anticholinergic side effects include dry mouth, constipation, and urinary retention. The nurse needs to assess the client's medication list to determine whether the client is taking an anticholinergic medication.
A nurse assesses a client with a fungal urinary tract infection (UTI). Which assessments should the nurse complete?
- A. Palpate the kidney and bladder
- B. Perform a medical history and assess current medical problems
- C. Perform a bladder scan to assess post-void residual
- D. Inquire about recent travel to foreign countries
- E. Obtain a current list of medications
Correct Answer: B,E
Rationale: Clients who are severely immunocompromised or who have diabetes mellitus are more prone to fungal UTIs. The nurse should assess for these factors by asking about medical history, current medical problems, and the current medication list.
After teaching a client who has stress incontinence, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?
- A. I must avoid drinking alcoholic beverages.
- B. I must avoid drinking alcoholic beverages.
- C. I must avoid drinking caffeinated beverages.
- D. I must try to drink caffeinated body weight.
Correct Answer: A
Rationale: Limiting fluids concentrates urine and can irritate tissues, leading to increased incontinence. Many people try to manage incontinence by limiting fluids. Alcohol and caffeinated beverages are bladder stimulants. Obesity increases intra-abdominal pressure, causing incontinence.