A client is receiving rehabilitation for paralysis following a spinal cord injury and is diagnosed with reflex incontinence. Which of the following is the highest priority intervention the nurse should include in the plan of care?

Limit fluid intake to prevent incontinence

Provide regular perineal care to prevent skin breakdown

Administer hypotonic IV fluids

Teach Kegel exercises to strengthen the pelvic floor

Answer and Explanation

The Correct Answer is B

Choice A: Limit fluid intake to prevent incontinence. This is incorrect because limiting fluid intake can lead to dehydration, urinary tract infections, and kidney stones. Fluid intake should be adequate to maintain hydration and flush out bacteria from the urinary tract.

Choice B: Provide regular perineal care to prevent skin breakdown. This is correct because reflex incontinence can cause urine leakage and skin irritation, which can increase the risk of infection and pressure ulcers. Regular perineal care can help keep the skin clean and dry, and prevent complications.

Choice C: Administer hypotonic IV fluids. This is incorrect because hypotonic IV fluids can cause fluid overload, hyponatremia, and cerebral edema. Hypotonic IV fluids are not indicated for clients with reflex incontinence.

Choice D: Teach Kegel exercises to strengthen the pelvic floor. This is incorrect because Kegel exercises are effective for clients with stress or urge incontinence, but not for clients with reflex incontinence. Reflex incontinence is caused by a loss of voluntary control over the bladder due to a spinal cord injury, and Kegel exercises cannot restore this function.

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Correct Answer is D

Explanation

Choice A reason: The AP's ability to complete the task without assistance is not one of the five rights of delegation. The nurse is responsible for providing adequate supervision and guidance to the AP, and ensuring that the task is done correctly and safely.

Choice B reason: The AP's ability to prioritize is not one of the five rights of delegation. The nurse is responsible for assigning tasks based on their urgency and importance and communicating clear expectations and deadlines to the AP.

Choice C reason: The AP's rapport with clients is not one of the five rights of delegation. The nurse is responsible for maintaining a therapeutic relationship with clients and respecting their preferences and needs.

Choice D reason: The AP has the knowledge and skill to perform the task is one of the five rights of delegation. The nurse is responsible for assessing the AP's competence and readiness to perform the task, and providing appropriate training and feedback if needed.

A. Fluconazole (Diflucan) B. Ciprofloxacin (Cipro) C. Varenicline (Chantix) D. Potassium iodide (KI)

Correct Answer is B

Explanation

Choice A reason: Fluconazole (Diflucan) is an antifungal medication that is used to treat infections caused by fungi, such as candidiasis, cryptococcosis, and histoplasmosis. It is not effective against anthrax, which is a bacterial infection caused by Bacillus anthracis.

Choice B reason: Ciprofloxacin (Cipro) is an antibiotic medication that belongs to the class of fluoroquinolones. It is used to treat various bacterial infections, including anthrax. It works by inhibiting the DNA synthesis of the bacteria and preventing them from multiplying. Ciprofloxacin is one of the recommended medications for post-exposure prophylaxis and treatment of anthrax, according to the Centers for Disease Control and Prevention (CDC).

Choice C reason: Varenicline (Chantix) is a medication that is used to help people quit smoking. It works by blocking the effects of nicotine on the brain and reducing the cravings and withdrawal symptoms. It has no role in the prevention or treatment of anthrax.

Choice D reason: Potassium iodide (KI) is a medication that is used to protect the thyroid gland from radioactive iodine in the event of a nuclear or radiological emergency. It works by saturating the thyroid with non-radioactive iodine and preventing it from absorbing radioactive iodine. It has no role in the prevention or treatment of anthrax.

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A client is receiving rehabilitation for paralysis following a spinal cord injury and is diagnosed with reflex incontinence. Which of the following is the highest priority intervention the nurse should include in the plan of care?

Nursing Test Bank

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