Nokea
The client is experiencing urinary incontinence. Which intervention should the nurse implement?
- A. Teach the client to drink prune juice weekly.
- B. Encourage the client to eat a high-fiber diet.
- C. Discuss the need to urinate every six (6) hours.
- D. Explain the importance of wearing cotton underwear.
Correct Answer: B
Rationale: A high-fiber diet prevents constipation, which can exacerbate incontinence by pressuring the bladder. Prune juice is too specific, voiding every 6 hours is too infrequent, and cotton underwear is secondary.
You may also like to solve these questions
The elderly client presents to the emergency department complaining of burning on urination with an urgency to void, and a temperature of 99.8°F. Which intervention should the nurse implement first?
- A. Ask the client to provide a clean voided midstream urine for culture.
- B. Insert an 18-gauge peripheral IV catheter and start normal saline fluids.
- C. Arrange for the client to be admitted to the medical unit.
- D. Initiate the ordered intravenous antibiotic medication.
Correct Answer: A
Rationale: Burning, urgency, and low-grade fever suggest a UTI. A midstream urine culture is the first step to confirm the diagnosis and guide treatment. IV fluids, admission, or antibiotics follow after diagnostic confirmation.
The laboratory data reveal a calcium phosphate renal stone for a client diagnosed with renal calculi. Which discharge teaching intervention should the nurse implement?
- A. Encourage the client to eat a low-purine diet and limit foods such as organ meats.
- B. Explain the importance of not drinking water two (2) hours before bedtime.
- C. Discuss the importance of limiting vitamin D-enriched foods.
- D. Prepare the client for extracorporeal shock wave lithotripsy (ESWL).
Correct Answer: C
Rationale: Calcium phosphate stones are linked to hypercalciuria. Limiting vitamin D-enriched foods reduces calcium absorption, preventing recurrence. Low-purine diets are for uric acid stones, water restriction is contraindicated, and ESWL is a treatment, not teaching.
Considering the amount of time the client must remain in bed, why is it imperative for the nurse to monitor for a urinary tract infection?
- A. The client will not be able to complete hygiene needs.
- B. The client will not be able to fully empty the bladder.
- C. The client will not be able to maintain bladder control.
- D. The client will not be able to drink sufficient fluids.
Correct Answer: B
Rationale: Prolonged bed rest can lead to incomplete bladder emptying, increasing the risk of urinary stasis and subsequent urinary tract infections.
The nurse is observing the UAP providing direct care to a client with an indwelling catheter. Which data warrant immediate intervention by the nurse?
- A. The UAP secures the tubing to the client’s leg with tape.
- B. The UAP provides catheter care with the client’s bath.
- C. The UAP puts the collection bag on the client’s bed.
- D. The UAP cares for the catheter after washing the hands.
Correct Answer: C
Rationale: Placing the collection bag on the bed risks contamination and infection, as it should be below bladder level and off surfaces. Securing tubing, providing care during bathing, and hand washing are appropriate.
The nurse is caring for a client diagnosed with rule-out nephrotic syndrome. Which intervention should be included in the plan of care?
- A. Monitor the urine for bright-red bleeding.
- B. Evaluate the calorie count of the 500-mg protein diet.
- C. Assess the client’s sacrum for dependent edema.
- D. Monitor for a high serum albumin level.
Correct Answer: C
Rationale: Nephrotic syndrome is characterized by massive proteinuria, hypoalbuminemia, and edema, often dependent (e.g., in the sacrum in bedridden clients). Assessing for dependent edema is a key intervention to monitor disease progression or response to treatment. Bright-red bleeding is not typical, a 500-mg protein diet is incorrect, and high serum albumin is not expected.