Nokea
The nurse is developing a care plan for a client experiencing urge urinary incontinence. Which interventions would be helpful for this type of incontinence? Select all that apply.
- A. Surgery
- B. Bladder retraining
- C. Scheduled toileting
- D. Dietary modifications
- E. Pelvic muscle exercises
- F. Intermittent catheterization
Correct Answer: B,C,D,E
Rationale: Urge incontinence is the involuntary passage of urine after a strong sense of the urgency to void. It is characterized by urinary urgency, often with frequency (more often than every 2 hours); bladder spasm or contraction; and voiding in either small amounts (less than 100 mL) or large amounts (greater than 500 mL). It can be caused by decreased bladder capacity, irritation of the bladder stretch receptors, infection, and alcohol or caffeine ingestion. Interventions to assist the client with urge incontinence include bladder retraining, scheduled toileting, dietary modifications such as eliminating alcohol and caffeine intake, and pelvic muscle exercises to strengthen the muscles. Surgery and urinary catheterization are invasive measures and will not assist in the treatment of urge incontinence.
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The nurse, caring for a client with Buck's traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?
- A. Weak pedal pulses
- B. Drainage at the pin sites
- C. Complaints of leg discomfort
- D. Toes demonstrating a brisk capillary refill
Correct Answer: A
Rationale: Buck's traction is skin traction. Weak pedal pulses are a sign of vascular compromise, which can be caused by pressure on the tissues of the leg by the elastic bandage or prefabricated boot used to secure this type of traction. Skeletal (not skin) traction uses pins. Discomfort is expected. Warm toes with brisk capillary refill is a normal finding.
The nurse is caring for a client diagnosed with active tuberculosis who is prescribed rifampin therapy. The nurse instructs the client to expect which side effect of this medication?
- A. Green urine
- B. Yellow sclera
- C. Orange secretions
- D. Clay-colored stools
Correct Answer: C
Rationale: Rifampin is an antituberculosis medication. Secretions will become orange in color as a result of the rifampin. The client should be instructed that this side effect will likely occur.
A client is in ventricular tachycardia and the primary health care provider prescribes intravenous (IV) lidocaine. The nurse should dilute the concentrated solution of lidocaine with which solution?
- A. Lactated Ringer's
- B. Normal saline 0.9%
- C. 5% Dextrose in water
- D. Normal saline 0.45%
Correct Answer: C
Rationale: Lidocaine for IV administration is dispensed in concentrated and dilute formulations. The concentrated formulation must be diluted with 5% dextrose in water. Therefore, options 1, 2, and 4 are incorrect.
An echocardiogram, chest x-ray (CXR), and computed axial tomography (CAT) scan are prescribed for a client who has activity intolerance. In which order should the nurse plan to schedule the procedures to meet the needs of this client safely and effectively?
- A. CAT scan and CXR in the morning, and echocardiogram on the following morning
- B. CXR and echocardiogram together in the morning, and CAT scan in the afternoon of the same day
- C. Echocardiogram in the morning, and CXR and CAT scans together in the afternoon of the same day
- D. CXR in the morning, echocardiogram in the afternoon, and CAT scan in the morning of the following day
Correct Answer: D
Rationale: CAT scans are always performed in radiology, and CXR and echocardiograms can be done at the bedside; however, the best results usually occur when the test is performed in the related department. As long as the client is stable and transportation is provided, the nurse can schedule each procedure in its department with two procedures on the first day separated by a rest period, and the remaining procedure the next day.
The nurse is assessing a client diagnosed with pleurisy 48 hours ago. When auscultating the chest the nurse is unable to detect the pleural friction rub, which was auscultated on admission. This change in the client's condition confirms which event has occurred?
- A. The prescribed medication therapy has been effective.
- B. The client has been taking deep breaths as instructed.
- C. The effects of the inflammatory reaction at the site decreased.
- D. There is now an accumulation of pleural fluid in the inflamed area.
Correct Answer: D
Rationale: Pleurisy is the inflammation of the visceral and parietal membranes. These membranes rub together during respiration and cause pain. Pleural friction rub is auscultated early in the course of pleurisy, before pleural fluid accumulates. Once fluid accumulates in the inflamed area, there is less friction between the visceral and parietal lung surfaces, and the pleural friction rub disappears. Options 1, 2, and 3 are incorrect interpretations.